Failure to Offer and Document PCV20 Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three out of five residents reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC). Documentation revealed that these residents had previously received PCV13 and PPSV23 vaccines, but there was no evidence that PCV20 was offered or that a shared clinical decision-making process occurred between the provider and the resident or their responsible agent regarding the administration of PCV20. The facility's own immunization review forms indicated that pneumococcal vaccinations were not up to date for some residents, and the vaccines were not offered as required. For each of the three residents, medical records and immunization reports confirmed the absence of documentation related to the offer or administration of PCV20. Consent or refusal forms for pneumonia immunizations were present in some cases, but the dates of vaccination were left blank, and there was no record of shared decision-making discussions. The regional nurse consultant and the infection preventionist both confirmed during interviews that PCV20 vaccinations had not been offered to residents, and that documentation of shared decision-making was lacking. The facility's policy on pneumococcal vaccines stated that education and administration of vaccines should be provided according to CDC recommendations, including the use of PCV15 or PCV20 for adults 65 years or older. However, the policy was not followed in practice, as evidenced by the lack of offers and documentation for PCV20 vaccination for the residents in question.