Failure to Screen, Educate, and Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility, educated about, and offered the recommended PCV20 or PCV21 pneumococcal vaccinations in accordance with current CDC guidance. Both residents had previously received PCV13 and PPSV23 vaccinations several years prior, making them eligible for the newer vaccines. However, their medical records did not indicate that they or their responsible parties were informed about or offered the PCV20 or PCV21 vaccines, nor was there documentation of shared decision-making regarding these immunizations. The facility's policy required informed consent, physician orders, education, and documentation for vaccine administration, but the process was not followed for these residents. During an interview, the Infection Preventionist acknowledged that the facility was using outdated guidance from 2015 and was unaware of the updated CDC recommendations to offer PCV20 or PCV21 to eligible residents. As a result, the necessary steps to assess, educate, and offer the vaccines were not completed for the two residents in question.