Failure to Document PCV20 Vaccine Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20) for several residents, as identified through record reviews and staff interviews. Specifically, five residents' records were reviewed for immunization status, and it was found that documentation was lacking for the offering, administration, or declination of the PCV20 vaccine. In some cases, records showed administration or declination of the PPSV23 vaccine, but there was no evidence that the PCV20 vaccine was addressed, nor was there documentation of a historical administration or physician-documented contraindication for PCV20. Interviews with nursing staff revealed inconsistencies in the tracking and administration process for immunizations. Staff members indicated that immunization status was tracked on the Treatment Administration Record (TAR) and by the infection preventionist, but there was uncertainty among staff regarding whether the PCV20 vaccine had been offered to residents. The facility's policy required adherence to state rules and incorporation of physician orders for pneumococcal vaccines, but the lack of documentation for PCV20 offerings or declinations indicated a failure to follow these procedures.