Failure to Administer Pneumonia Vaccines per Consent and Policy
Penalty
Summary
The facility failed to administer pneumonia vaccines to two residents who were due for them and had signed consents to receive the vaccine, as required by the facility's immunization policy and CDC guidelines. One resident, who had a history of vascular dementia and diabetes, had previously received both Pneumovax 23 and Prevnar 13 vaccines, and had a signed consent for another pneumonia vaccine. However, the vaccine was not administered because, at the time of consent, the resident was not yet due, and the Infection Preventionist did not follow up when the resident became eligible. Another resident, with diagnoses including diabetes and chronic obstructive pulmonary disease, had a record of a previous pneumonia vaccine of unknown type and had signed two consents for the pneumonia vaccine. Despite this, no order was placed for the vaccine, so it was neither obtained from the pharmacy nor administered. The Infection Preventionist confirmed these lapses during interviews, and the Director of Nursing stated that vaccinations were expected to be administered per CDC guidelines and resident requests.