Failure to Educate, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide education regarding the benefits and possible side effects of a pneumococcal immunization, offer the immunization, and document either refusal or administration for one resident with a diagnosis of COPD who was a current tobacco user and moderately cognitively impaired. The resident's medical record did not contain any documentation of education about the pneumococcal vaccine, consent or refusal, or evidence that the vaccine had been administered. Interviews with the resident and her responsible party confirmed that neither recalled being offered the vaccine or receiving education about it, and both indicated willingness to accept the vaccine if it had been offered. The Infection Preventionist acknowledged awareness of residents not being up to date with pneumococcal vaccines and described an ongoing process to address the issue, starting with new admissions and proceeding chart by chart. However, the resident in question had not yet been included in this process. The Director of Nursing and the Administrator both confirmed the absence of required documentation for education, consent, refusal, or administration of the pneumococcal vaccine for this resident. The Medical Director also stated that the resident should have been offered the vaccine.