Failure to Offer and Document Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to offer the pneumococcal vaccine and provide education regarding its benefits and potential side effects to two residents whose records were reviewed for infection control. Both residents were admitted to the facility with no documentation in their medical records indicating that the pneumococcal vaccine was offered or that education about the vaccine was provided. The admission Minimum Data Set (MDS) assessments for both residents showed their pneumococcal vaccinations were not up to date, and there was no evidence of an offer or education regarding the vaccine. Interviews with the DON confirmed that there was no documentation of vaccine education or offering in the residents' records. One resident also stated they did not recall any discussion about the pneumonia vaccine upon admission. The Infection Preventionist and Administrator both stated that it was the facility's expectation to provide education and document acceptance or refusal of immunizations during the admission process. Review of the facility's immunization policy confirmed that education and documentation are required for all residents, but these steps were not followed for the two residents in question.