Failure to Document and Update Pneumococcal Vaccination Practices
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation indicating whether the pneumococcal vaccine (PCV20 or PCV21) was offered, received, or refused, or if there were medical contraindications. Specifically, for two residents who were readmitted to the facility, their immunization records showed they had previously received PCV13 and PPSV23 vaccines, but there was no evidence in their records regarding the offering or administration of the updated pneumococcal vaccines as recommended by current CDC guidelines. During staff interviews, the Infection Preventionist was unable to provide documentation that these residents had been offered or had declined the PCV20 or PCV21 vaccine. Additionally, the facility's policy on resident vaccination for flu and pneumonia was found to be outdated. The policy referenced guidelines from 2019 and did not include the most recent recommendations for pneumococcal immunizations. The Director of Nursing Services acknowledged during an interview that the current policy did not reflect the latest guidance, contributing to the lack of proper documentation and adherence to updated vaccination protocols.