Failure to Ensure Pneumococcal Vaccination Offer and Documentation
Penalty
Summary
The facility failed to maintain a comprehensive system to ensure that residents received pneumococcal immunizations as recommended. For four out of five sampled residents, immunization records indicated that pneumococcal vaccinations were due or the last administration date was either unknown or exceeded the recommended interval. There was no documentation in the medical records that these residents had been offered the pneumococcal vaccine, received education about it, or had signed declination forms if they refused the vaccine. The facility's policy required identification of residents needing the vaccine and the use of a decision tree to determine eligibility, but this process was not followed for the affected residents. During interviews and record reviews, it was confirmed that the residents in question had not been offered the pneumococcal vaccine upon admission or during their stay, despite being due for it according to CDC guidelines and facility policy. The Director of Nursing acknowledged the lapse in the process and indicated awareness that the residents were overdue for vaccination, but no evidence was found in the records to show that the required steps had been taken to offer, educate, or document refusal of the vaccine for these residents.