Failure to Administer Pneumococcal Vaccines per CDC Recommendations
Penalty
Summary
The facility failed to administer pneumococcal vaccinations according to CDC recommendations for three residents who had provided signed consents for the vaccine. All three residents had severe cognitive impairment and had consents for the pneumococcal vaccine documented in their medical records. However, there was no evidence in the medical records that the vaccine was actually administered to any of these residents, despite the consents being in place. Interviews with the Infection Preventionist revealed that she was aware of the lack of vaccine administration and attributed it to the facility's inability to obtain the vaccine from the pharmacy. The Director of Nurses was not aware of the issue with vaccine procurement and stated that the vaccine should have been administered if consent was obtained. The facility's policy requires that all residents receive recommended immunizations unless contraindicated, refused, or otherwise ordered by a physician, and that consent and orders for vaccines be obtained at admission, but these procedures were not followed through to completion for the affected residents.