Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that two residents were offered or received pneumococcal vaccinations in accordance with CDC recommendations. Review of immunization records showed that one resident had previously received the PPSV23 vaccine, and another had received both the PCV13 and PPSV23 vaccines, but neither had documentation indicating they were offered or received the updated PCV20 or PCV21 vaccines. Both residents had provided consent for the updated vaccinations, but there was no evidence in their medical records that the immunizations were administered. Interviews with the infection preventionist (IP) revealed that the pharmacist responsible for administering the vaccines was not contacted to provide the immunizations until an email was sent, and there was no indication that the specific residents were included in the request. The IP confirmed that, despite consent being obtained, the vaccinations had not been given, and the pharmacist had not been contacted prior to the recent email. The director of nursing (DON) acknowledged that the residents should have received the updated immunizations according to CDC guidelines. Facility policy stated that immunizations would be offered in accordance with CDC recommendations, but this was not followed for the two residents identified.