Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
Facility staff failed to offer pneumococcal conjugate vaccines (PCV20 or PCV21) to two residents following their admission, despite both having previously received PCV13 and being assessed as not up to date with pneumococcal vaccination. For both residents, clinical records and the Minimum Data Set (MDS) indicated moderate cognitive impairment and documented that the pneumococcal vaccine was not up to date, with the stated reason being that it was not offered. Both residents had significant medical histories, including Alzheimer's disease and other chronic conditions. The facility's policy required assessment and offering of pneumococcal immunization upon admission in accordance with CDC guidelines, with documentation of efforts to obtain immunization history. However, staff interviews and record reviews revealed that these steps were not completed for the two residents in question. The assistant director of nursing, who also served as the infection preventionist, was unable to provide documentation that the vaccine had been offered or administered, and no further information was provided prior to the survey exit.