Failure to Administer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who was eligible and had provided consent. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine within thirty days unless medically contraindicated or previously vaccinated. The resident in question, who had a history of diabetes mellitus and acute pyelonephritis, was admitted in February 2022 and had received a dose of Prevnar 13 (PCV13) in May 2019, prior to admission. There was no evidence in the clinical record that the resident had received any additional pneumococcal vaccinations after the PCV13 dose, despite having signed a consent for the vaccine upon admission. CDC guidelines recommend that adults over a certain age who have previously received PCV13 should receive a dose of PCV20 or PCV21 at least one year later. The facility's Director of Nursing confirmed during an interview that the resident should have received the pneumococcal vaccine but had not. The failure to administer the vaccine occurred despite the presence of a signed consent and clear eligibility, as indicated by both facility policy and CDC recommendations.