Failure to Offer and Document Pneumococcal Vaccine per Facility Policy
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to one of seven sampled residents, as required by its own policy. The resident in question was originally admitted in 2019 and re-admitted in 2025 with diagnoses including acute respiratory failure with hypoxia, sepsis, and diabetes mellitus. Review of the resident's Minimum Data Set indicated moderately impaired cognition and dependence on staff for activities of daily living. During a review of the resident's immunization record, it was found that the last pneumococcal vaccine dose was administered in 2023, but the required consent form for the vaccine was missing, and there was no documentation that the vaccine had been offered as per policy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the resident was due for a second dose of the pneumococcal vaccine and that the facility was responsible for verifying and offering the vaccine to all residents as needed. The facility's policy stated that all residents should be evaluated for pneumococcal vaccination status upon admission and offered the vaccine unless medically contraindicated or already immunized. The failure to offer and document the vaccine for this resident constituted a deficiency in following established procedures.