Failure to Administer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to a resident who was eligible and had provided consent to receive it. According to the facility's Infection Control - Vaccination Policy, residents are to be offered immunizations in accordance with CDC guidelines unless medically contraindicated or previously vaccinated. Clinical record review showed that the resident had previously received both the PPSV23 and PCV13 vaccines, with the last dose administered more than five years prior to the current review. Despite this, there was no documentation that the interdisciplinary team reviewed the resident's condition or made a decision regarding the administration of a subsequent dose of PCV20 or PCV21, as recommended by CDC guidelines for adults who have completed the earlier vaccine series. The resident's responsible party had signed a consent form for pneumococcal vaccination, indicating willingness to proceed with further immunization. However, staff interviews confirmed that the resident was not offered the vaccine, and there was no evidence of shared clinical decision-making or assessment for additional vaccination. The deficiency was identified through policy review, clinical record examination, and staff interviews, and was confirmed by the infection control prevention coordinator and discussed with the Nursing Home Administrator.