Failure to Offer Recommended Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal conjugate vaccines (PCV 20, PCV 21, or PCV 15) to a resident who had previously received only the PPSV23 vaccine, as required by current CDC recommendations. The facility's policy stated that all residents would be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine series within thirty days if indicated, with administration to follow CDC guidelines. However, review of the resident's medical record and the California Immunization Registry (CAIR2) confirmed that the resident had only received PPSV23 and was not offered any of the recommended PCV vaccines after that dose. During an interview, the Infection Preventionist (IP) stated that vaccination status was reviewed upon admission and annually, relying on CAIR2 data and family input. The IP believed, based on pharmacy consultant advice, that a new vaccine was not needed until five years after the PPSV23 dose, which was inconsistent with updated CDC guidelines. The IP confirmed that the resident's pneumococcal vaccination status was not up to date according to current recommendations, and there was no documentation showing the resident was offered the appropriate PCV vaccine.