Failure to Administer Pneumococcal Vaccine After Resident Consent
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease (COPD), skin cancer, and recent scalp surgery was admitted to the facility and was found to be cognitively intact and able to make her own medical decisions. The resident provided written consent to receive the pneumococcal vaccine (PVC 20) on 7/26/2025. However, a review of the immunization record and medication administration record (MAR) for July and August 2025 showed that the vaccine was not administered, resulting in a delay of 25 days since the resident's request and consent. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that facility policy requires the PVC 20 vaccine to be ordered and administered within 72 hours of obtaining resident consent. In this case, the IP did not place the order for the vaccine, and the resident did not receive the immunization as required by facility policy. The facility's policy and procedure on pneumococcal vaccination states that all residents will be offered the vaccine unless medically contraindicated, already given, or refused, but this protocol was not followed for the resident in question.