Failure to Offer and Document Pneumococcal Vaccinations for Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered or refused as required for eligible residents. This deficiency was identified through interviews and record reviews, which revealed that three out of five residents whose immunization records were reviewed did not have documentation of being offered the pneumococcal vaccine upon admission. In each case, the lack of documentation persisted until after the surveyor requested evidence, at which point verbal consents were obtained. Specifically, one resident with a history of pulmonary embolism, lobar pneumonia, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and chronic systolic heart failure was admitted without any record of being offered the pneumococcal vaccine. The Wisconsin Immunization Registry also did not show any record of administration, and the resident was eligible for the vaccine. Two other residents, both cognitively intact and with significant medical histories including enterocolitis, diabetes, COPD, heart failure, cellulitis, and sepsis, similarly lacked documentation of being offered or refusing the vaccine upon admission, despite being eligible. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding regarding the requirement to offer vaccinations to short-term residents and was unaware that this should be addressed at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility had recently held a vaccination clinic but had not ensured all eligible residents were offered the vaccine at admission. No further evidence was provided to show that the vaccine was offered or refused by the residents at the appropriate time.