Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received pneumococcal vaccinations as required by their own policy and current recommended practice guidelines. For one resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, diabetes, and chronic kidney disease, records showed that the pneumococcal vaccine was not up to date and had not been offered. The resident's immunization record confirmed that neither the vaccine was administered nor the offer documented. For another resident, who was cognitively intact and had diagnoses including cerebral infarction and hemiplegia, the Minimum Data Set indicated the vaccine was up to date, but there was no supporting documentation in the immunization record to confirm administration or offer of the vaccine. During interviews, the DON confirmed that both residents had not received or been offered the pneumococcal vaccination prior to recent attempts to obtain consent or offer the vaccine. The DON also acknowledged the lack of evidence to support claims that the residents or their representatives had previously been offered the vaccination or had refused it. The facility's policy required that residents be offered the pneumococcal vaccination and that refusals be documented, but this was not done for the two residents reviewed.