Failure to Document Consent or Declination for PCV20 Vaccination
Penalty
Summary
The facility failed to obtain and document consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for several residents. Specifically, clinical records for four residents lacked evidence that the PCV20 vaccine was offered or declined, and there was no documentation of prior administration or physician-documented contraindications. In some cases, records showed that other pneumococcal vaccines (such as PCV13 or PCV23) were pending or had been administered, but there was no follow-up or documentation regarding the PCV20 vaccine as required. Interviews with nursing staff revealed that immunization status was typically assessed on admission and that the process involved the nurse in charge, the DON, and the pharmacy. However, the records did not reflect that the required steps for offering or documenting the PCV20 vaccine were consistently followed. The facility's policy stated that pneumococcal immunizations would be offered in accordance with CDC guidelines, but the lack of documentation for these residents indicated that the policy was not fully implemented.