Failure to Timely Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure timely offering and documentation of pneumococcal vaccines for four out of eight residents reviewed. For several residents with significant medical histories, including dementia, diabetes, stroke, and chronic respiratory conditions, the clinical records and preventative health documentation did not reflect up-to-date pneumococcal vaccine status or evidence that the vaccine was offered as required. In some cases, the vaccine was not offered at all, while in others, only one type of pneumococcal vaccine was offered without education or re-offering of other recommended vaccines. Documentation of vaccine status and education was also missing from the residents' records. Interviews with the infection preventionist LPN revealed inconsistent practices, such as missing vaccine offers due to form discrepancies, not re-offering vaccines after initial refusal, and not considering eligibility based on comorbidities. The facility's policy required assessment and offering of pneumococcal vaccines upon admission or readmission, with proper education and documentation, but these steps were not consistently followed. The medical director confirmed that the residents in question were eligible for vaccination according to CDC guidelines.