Failure to Screen and Document Pneumococcal Vaccination for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal vaccination policies for two residents reviewed under the infection control task. Resident 85 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, and was documented in the H&P and MDS as lacking capacity to understand or make decisions and being dependent on staff for all ADLs. The immunization record for this resident showed receipt of Prevnar 13 on 12/27/2012, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor was there documentation of a medical contraindication. Additionally, the facility’s 2025–2026 flu, pneumonia, and COVID consent tracker did not list this resident at all. Resident 41 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and cerebral palsy, and the H&P and MDS documented that the resident lacked capacity to understand or make decisions and was dependent on staff for all ADLs. The immunization record indicated Pneumovax 23 was administered on 5/9/2003, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor any documentation of a medical contraindication. The facility’s consent tracker listed this resident as completed for the pneumonia vaccine despite the absence of documentation of updated vaccination, consent, or declination in the medical record. The Infection Preventionist stated that, per current CDC and ACIP adult immunization guidelines, both residents were eligible for and recommended to receive updated pneumococcal conjugate vaccines, and the DON acknowledged that not offering vaccines upon admission was not aligned with the facility’s policies, which require all new residents to be assessed for vaccination status and offered the pneumococcal pneumonia vaccine with consent or refusal documented in the record.
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