Failure to Document and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that each resident was offered the pneumococcal vaccine and that proper documentation was maintained in the medical record. Specifically, for one sampled resident with chronic diastolic heart failure, emphysema, and unspecified dementia, there was no documentation indicating whether the pneumococcal vaccine was offered, received, refused, or medically contraindicated. Review of the resident's admission immunization record revealed that none of the options regarding the pneumococcal vaccine were marked, and there was no evidence in the medical record of the resident's immunization history or that the vaccine had been offered. Interviews with nursing staff and the Infection Preventionist confirmed that the process for offering and documenting vaccines relied on forms completed at admission and follow-up by the Infection Preventionist. However, in this case, the required documentation was missing from the resident's record. Staff stated that vaccines, including pneumococcal, were to be offered and documented upon admission, but this was not completed for the resident in question.