Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination history was maintained and that the pneumococcal vaccine was administered after consent was obtained for three residents. For one resident admitted with severe protein-malnutrition, adult failure to thrive, and cerebral infarction, the immunization consent form indicated that the resident's representative had provided consent for the pneumococcal vaccine, and there was no record of prior vaccination. However, the vaccine was not administered, and the resident's medical record did not reflect an up-to-date vaccination status or an offer of the vaccine, despite severe cognitive impairment. Another resident, admitted over the age of 50, had signed a consent form indicating no prior pneumococcal vaccination and had agreed to receive an updated vaccine as needed. Similarly, a third resident's representative had consented to updated pneumococcal vaccination, but there was no documentation of previous vaccination, and the vaccine was not administered. Staff interviews confirmed that vaccination history should be obtained at admission, documented, and, if not up-to-date, consent and a physician's order should be secured to provide the vaccine shortly after admission. Despite facility policy requiring documentation of education, consent, and administration or refusal of the pneumococcal vaccine, and CDC guidance recommending vaccination for adults over 50 without prior immunization, the facility did not administer the vaccine to these residents after obtaining consent. The Director of Nursing and Infection Preventionist acknowledged that the vaccines should have been administered shortly after admission, but this did not occur for the identified residents.