Failure to Document and Administer Pneumococcal Vaccine per Policy
Penalty
Summary
The facility failed to follow its Pneumococcal Immunization Policy by not ensuring accurate documentation and administration of the pneumococcal vaccine for one resident. The resident, who was moderately cognitively impaired and had diagnoses including type 2 diabetes mellitus and cough, was admitted with unclear vaccination history. The resident's face sheet and continuity of care documents indicated a completed pneumococcal vaccine, but did not specify the type of vaccine administered. Consent for vaccination was obtained from the resident's Power of Attorney, who was unable to recall the resident's prior vaccination history. Staff interviews revealed that vaccination history was typically obtained from the resident, family, or physician, but there was no documentation of communication with the physician regarding the resident's pneumococcal vaccination status. The business office manager attempted to retrieve records from the local hospital, which showed the resident had received PCV13 vaccines on two occasions, but there was no reproducible evidence that the facility itself administered any pneumococcal vaccine. Additionally, the infection prevention nurse was not aware of the specific CDC guidelines or the use of the recommended app for determining vaccine schedules, and could not confirm the resident's vaccination status.