Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations or physician-documented contraindications for the Pneumococcal Conjugate Vaccine (PCV20) and pneumococcal vaccination for several residents. Specifically, record reviews showed that while the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined for some residents, there was no documentation that the PCV20 was offered, declined, or previously administered, nor was there a physician-documented contraindication. This lack of documentation was noted for multiple residents in the sample reviewed. Interviews with nursing staff revealed that vaccinations were typically offered at admission, and if consented, ordered from the pharmacy and documented in the electronic medical record. However, the records for certain residents did not reflect that the PCV20 vaccine was addressed according to policy. The facility's own policy required that each resident be offered pneumococcal immunization unless medically contraindicated or already immunized, with appropriate documentation in the medical record, but this was not consistently followed.