Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer or administer the pneumococcal vaccine to three out of five residents reviewed for immunizations, despite having policies in place to assess and vaccinate residents according to CDC recommendations. In one case, a resident with respiratory failure and lung cancer, who had intact cognition, consented to receive the pneumococcal vaccine upon admission, but there was no documentation that the vaccine was administered. The administrator confirmed that staff did not follow through with obtaining an order for the vaccine, despite the resident's family member consenting to vaccination. Another resident with acute and chronic respiratory failure and COPD, also with intact cognition, had previously received both Prevnar 13 and Pneumovax but had not been offered or administered a pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) as recommended five years after the last dose. The clinical record lacked documentation that the vaccine was offered or refused in the years following eligibility, and the resident only recalled being offered the vaccine on admission and again during the survey process. A third resident, with iron deficiency anemia, moderate intellectual disability, and a history of blood clots, had received Pneumovax but had not been offered a pneumococcal conjugate vaccine after becoming eligible. The resident's guardian had consented to other vaccinations but was not given the opportunity to consent or refuse the pneumococcal conjugate vaccine. The DON, responsible for immunization tracking, reported only recently learning the pneumococcal vaccine schedule and had not run reports to identify eligible residents until prompted by the surveyor.