Failure to Offer and Administer Pneumococcal Vaccines 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 recommended pneumococcal vaccine series according to CDC guidelines. Specifically, one resident with diagnoses including dementia, diabetes, rheumatoid arthritis, and epilepsy had received PPSV23 and PCV13 in previous years and had a signed consent for further pneumococcal vaccination, but there was no evidence that the PCV20 or PCV21 vaccine was administered. Another resident with Alzheimer's disease, anxiety disorder, and peripheral vascular disease had received PCV15 and had a signed consent for additional pneumococcal vaccination, but there was no documentation of receiving PPSV23, PCV20, or PCV21. A third resident with adult failure to thrive, depression, and osteoporosis had not received any pneumococcal vaccinations, nor was there evidence that the vaccine was offered. The director of nursing confirmed that the facility did not administer the requested or consented pneumococcal vaccinations to two residents and failed to offer the vaccine to a third resident. The facility's policy stated that immunizations should be offered in accordance with current CDC guidelines, but documentation and interviews revealed that this was not consistently followed for the residents reviewed.