Failure to Administer Pneumococcal Vaccine per Updated CDC Guidelines
Penalty
Summary
The facility failed to follow the CDC 2025 Adult Immunization Schedule for pneumococcal vaccination for one resident. The resident was admitted to the facility and had previously received a pneumococcal 23 vaccination several years prior. Upon admission, the resident consented to receive the pneumococcal vaccine, and an active provider order was in place for administration if applicable. Pharmacy consultant notes recommended administration of Prevnar 20 and advised nursing to obtain consents and enter them into the EHR. However, the updated CDC guidelines indicated that the resident was eligible for an additional pneumococcal vaccine, which was not administered. Staff interviews revealed uncertainty regarding responsibility for reviewing pneumococcal vaccination status during the admission process. The facility's policy required assessment of vaccination eligibility within five working days of admission and offering the vaccine within thirty days if indicated, but did not specify who was responsible for this assessment. As a result, the resident did not receive the recommended pneumococcal vaccination according to the most recent guidelines.