Failure to Administer Indicated Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to one resident who was eligible and had consent from the responsible party. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine within ninety days if indicated. The resident in question had previously received PCV13 and PPSV23 vaccines prior to admission, and the CDC's current recommendations indicated that the resident was due for another dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine. The resident's clinical record showed that consent for the vaccine was obtained and a physician's order was in place, but there was no evidence that the vaccine was administered when the resident became eligible. The deficiency was identified through interview and record review, which confirmed that the resident, who had diagnoses including hemiplegia, hemiparesis, and dysphagia, did not receive the indicated pneumococcal vaccine despite meeting all criteria. The Director of Nursing acknowledged that the resident should have received the vaccine in 2024 but had not. This lapse was in direct violation of both facility policy and CDC recommendations for pneumococcal vaccination in adults.