Failure to Offer and Document Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered or provided an updated pneumococcal vaccination in accordance with CDC recommendations. The resident in question was an older adult with a history of non-Hodgkin lymphoma, anemia, and dementia, who had previously received PPSV-23 and PCV-13 vaccines. Despite facility policies requiring assessment of immunization status within five days of admission and offering the vaccine within thirty days if indicated, the medical record did not contain evidence that the resident was offered the updated pneumococcal vaccine or had signed a declination form. Document review showed that standing orders and facility policy aligned with CDC guidelines, mandating documentation of vaccination status, administration details, and periodic audits by the Infection Preventionist. However, the resident's medical record lacked documentation of being offered the vaccine or declining it, and the Minimum Data Set incorrectly indicated that vaccines were up to date. The DON confirmed the expectation that vaccines should be current, highlighting the gap between policy and practice.