Failure to Offer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal conjugate vaccine to one of five sampled residents reviewed for immunizations. According to the clinical record, the resident had previously received a dose of Pneumovax (PPSV23) in 2010 and was over the age threshold at the time. The resident's record did not contain documentation that staff had offered or administered a pneumococcal conjugate vaccine (such as Prevnar 20, Prevnar 21, or Vaxneuvance) in accordance with current CDC guidelines. The Infection Preventionist confirmed that the resident should have been offered the vaccine based on their immunization history. Facility policy required nursing staff to screen residents for pneumonia vaccination status upon admission, provide education on the risks and benefits of the pneumococcal vaccine, and document both the education and the resident's consent or declination. However, the review found that this process was not followed for the resident in question, as there was no evidence of an offer, education, or documentation regarding the pneumococcal conjugate vaccine. The deficiency was identified through clinical record review, policy review, CDC guideline comparison, and staff interviews.