Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that the medical records of three residents included documentation indicating whether the residents received the pneumococcal vaccination, or if not, whether it was declined or medically contraindicated. Specifically, for three residents admitted between 2018 and 2019, record reviews showed that while initial pneumococcal vaccine series (PCV13 and PPSV23) were completed, there was no evidence that the newer recommended vaccines (PCV20 or PCV21) were offered, administered, or declined. In one case, a resident consented to a pneumococcal vaccination, but there was no documentation that the vaccine was actually given or refused. During an interview, the DON confirmed that the facility had not documented whether these residents received or declined the updated pneumococcal vaccines, and was unable to provide such evidence until prompted by the surveyor. The lack of documentation was only identified after the surveyor brought the issue to the facility's attention.