Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to properly screen, offer, provide education, and document consent or refusal for the pneumococcal immunization for one resident. Clinical record review showed that the resident, who was cognitively intact, had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as per updated CDC guidelines. Staff interviews confirmed that the expectation was for vaccinations to be offered according to resident preference, with education provided if refused. The facility's own policy required offering the pneumococcal immunization unless contraindicated or already administered, and mandated education about benefits and side effects prior to offering the vaccine. However, these steps were not documented for the resident in question.