Failure to Offer, Administer, or Document Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer, administer, or document the pneumococcal vaccine for one resident who was reviewed for immunizations. According to the facility's policy, residents are to be assessed for eligibility and offered the pneumococcal vaccine series within 30 days of admission unless medically contraindicated or previously vaccinated. The resident in question was admitted to the facility and was found to be cognitively intact. The Minimum Data Set indicated the vaccine was offered and declined, but there was no signed consent, administration record, or documentation of refusal in the resident's electronic health record. Interviews with the resident revealed that he had not been offered the pneumococcal vaccine since admission. The DON, who also served as the Infection Preventionist, was unable to confirm whether the vaccine had been offered or administered and could not locate any documentation in the paper or electronic records. The Corporate Nurse Consultant also confirmed there was no documentation available and acknowledged that there were areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.