Failure to Update Pneumococcal Immunization Policy to Include PCV21
Penalty
Summary
The facility failed to update its policies and procedures to include the most current standards of practice regarding pneumococcal immunizations, specifically omitting the newly available PCV21 vaccine. Review of the facility's pneumococcal vaccine policy, last revised in October 2023, showed that it referenced PCV15, PCV20, and PPSV23, but did not mention PCV21. The Director of Nursing (DON) and Infection Preventionist confirmed during interviews and record reviews that they were unaware of the release and availability of PCV21, and that the facility's immunization schedule and policy did not include this vaccine. The CDC's updated recommendations and vaccine timing charts, which now include PCV21, were not being used by the facility at the time of the survey. For two residents reviewed for immunizations, immunization reports did not address PCV21. One resident was noted as not eligible for PCV20 or PCV15, with no mention of PCV21, and another had received PCV13 and PPSV23, but there was no documentation regarding PCV15, PCV20, or PCV21. The DON confirmed that PCV21 was not available or offered at the facility, and that the policy and immunization tracking tools had not been updated to reflect the latest CDC guidance. This failure to update policies and procedures created the potential for eligible residents to not be offered the PCV21 vaccine.