Failure to Document and Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
A deficiency was identified when the facility failed to offer or document the administration or declination of the second dose of the pneumococcal immunization series for one resident. The resident, who had a medical history including a right fibula fracture, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, a prosthetic heart valve, cardiomyopathy, and hypertension, had received the PCV-13 pneumococcal vaccine. However, there was no documentation in the medical record indicating that the resident was administered, offered, or declined the subsequent recommended pneumococcal vaccine. The facility's process involved the ADON checking the Statewide Immunization Information System for new admissions and completing a vaccine form. In this case, the resident's vaccination consent form was marked as "unable to determine" for the pneumococcal vaccine, and the DON confirmed that there was no evidence of the second vaccine being offered or declined. The facility's policy required assessment and offering of the pneumococcal vaccine series upon admission, with documentation of administration or refusal, but this was not followed for the resident in question.