Failure to Offer and Document Pneumococcal Immunization
Penalty
Summary
A deficiency was identified when the facility failed to offer and document pneumococcal immunization for one resident out of five reviewed for infection control. According to facility policy, licensed nurses are required to obtain consent for pneumococcal vaccination upon admission and document the immunization history in the resident's electronic health record. The resident in question was admitted with diagnoses including traumatic subarachnoid hemorrhage and anemia and was assessed to have intact cognition. However, during the survey, the Director of Nursing confirmed that there was no documentation of pneumococcal vaccine being offered or administered to this resident. This finding was reviewed with facility leadership during the exit conference.