Failure to Offer Required Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer the PCV15 or PCV20 pneumococcal vaccination to a resident who had previously received the PPSV23 vaccine, as required by both the facility's policies and CDC guidelines. The resident, aged 93, was admitted to the facility and had documentation showing receipt of the PPSV23 vaccine in 2013. Upon admission, the responsible party declined consent for further pneumococcal vaccination, citing the previous PPSV23 dose as the reason. However, the facility's policy and CDC recommendations specify that adults aged 65 and older who have only received PPSV23 should be offered a dose of PCV15 or PCV20 at least one year after the last PPSV23 vaccination. Medical record review and the California Immunization Registry confirmed that the resident had not received PCV15 or PCV20, and there was no documentation that the vaccine was offered in accordance with current guidelines. The facility's immunization report also did not show administration of PCV15 or PCV20. During an interview, the Infection Preventionist verified that the resident's records did not reflect the required offer or administration of the additional pneumococcal vaccine, as outlined in the facility's policy and CDC recommendations.
Plan Of Correction
F883 Influenza and Pneumococcal Immunizations. Failed to follow up subsequent vaccine. • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Offered pneumococcal vaccine to resident/responsible party on 6/19/25. The responsible party declined the vaccine on 6/19/25. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. An audit of the pneumococcal vaccinations for all residents was done on 6/24/25 by the IP nurse. No other residents were found. IP was inserviced 6/24/25 by DON about resident pneumonia vaccinations being offered annually. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. DSD will audit the pneumococcal vaccine log once a week x 3 months. Significant findings will be reported to the DON. • How the facility plans to monitor its performance to make sure that solutions are sustained. IP nurse provide a summary of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 6/24/25