Failure to Assess and Administer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for and administered the pneumococcal vaccine as required. One resident, who had diagnoses including Alzheimer's disease, atrial fibrillation, and chronic systolic congestive heart failure, was admitted with severely impaired cognition. Despite providing consent for the pneumococcal vaccination series, there was no documentation in the clinical records that the vaccine was administered or refused. The Infection Preventionist confirmed that the resident should have received the vaccine upon consent, and it was the responsibility of the previous Infection Preventionist to ensure this process was completed. Another resident with diagnoses of type 2 diabetes mellitus, Alzheimer's disease, chronic kidney disease stage 3, and hyperlipidemia also had severely impaired cognition and had not received or been offered the pneumococcal vaccine. Clinical records did not show any prior vaccination history or documentation of refusal. The Infection Preventionist stated that the process involves the admitting nurse offering the vaccine, followed by review and administration by the Infection Preventionist, but acknowledged that this was not completed for the resident in question. Facility policy requires all residents to be evaluated and offered the pneumococcal vaccine per CDC guidelines, but this was not followed in these cases.