Failure to Offer Updated Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer pneumococcal vaccines in accordance with current CDC recommendations to three of five residents reviewed for immunizations. Facility policy required that all residents receive appropriate pneumococcal vaccines unless contraindicated or refused, with immunization status determined at admission and documented in the electronic medical record. However, clinical record reviews revealed that one resident, admitted at age 83, had only received a PPSV23 vaccine prior to admission, with no evidence of being offered additional recommended pneumococcal vaccines such as PCV15, PCV20, or PCV21. Two other residents, both of whom had received PCV13 and PPSV23 prior to admission, also had no documentation indicating they were offered the newer pneumococcal vaccines as recommended by current CDC guidance. Interviews with the infection control prevention coordinator confirmed that there was no additional evidence of these residents being offered the appropriate pneumococcal immunizations. The facility's active policy did not reference the newer available vaccines (PCV15 or PCV21), and there was no documentation of offers or administration of these vaccines in the residents' medical records. These findings were based on a review of facility policies, clinical records, and staff interviews.