Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four out of five sampled residents reviewed for immunizations, despite CDC guidelines and facility policy requiring assessment and offering of the vaccine within 30 days of admission. The Director of Nursing (DON) acknowledged that some residents were eligible for the vaccine but had not been offered it, citing issues such as difficulty accessing the Iowa Immunization Registry Information (IRIS) account and discrepancies between hard chart, electronic records, and a separate file maintained by the DON. A recent pharmacy audit had also identified residents in need of vaccines, but the necessary follow-up had not occurred. Clinical record reviews revealed that several residents, including those with significant medical histories such as diabetes, dementia, coronary artery disease, COPD, and heart failure, either lacked documentation of being offered or receiving the appropriate pneumococcal vaccines per current CDC guidelines. In some cases, residents had received earlier versions of the vaccine but had not been offered the updated vaccines as recommended. Interviews with residents and staff confirmed that eligible residents had not been offered the vaccine, and the facility's policy, last updated in 2017, was not being followed as required.