Failure to Follow Policy for Timely Pneumococcal Vaccination of New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pneumococcal vaccination policy by not screening and offering the pneumonia vaccine to new residents within the first week of admission. The facility’s policy, titled “Pneumococcal Vaccinations” and reviewed on 1/6/2025, states that all current residents or their responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually, if eligible. Record review showed that four residents’ immunization reports contained no documentation that a pneumococcal vaccine was offered or given since admission. These four residents included an older male with multiple diagnoses such as cerebral infarction, type II DM, obesity, epilepsy, sleep apnea, and acute kidney failure; an older female with rhabdomyolysis, protein calorie malnutrition, HTN, cellulitis, CAD, and depression; an older male with muscle disorder, gait and mobility abnormalities, lack of coordination, intracerebral hemorrhage, HTN, hemiplegia, dysphagia, and anxiety; and an older female with venous insufficiency, gait and mobility abnormalities, protein calorie malnutrition, acute respiratory failure, type II DM, and COPD. During an interview, the Infection Preventionist stated that the facility does not offer the pneumococcal vaccine to new admissions immediately upon entering the facility, but instead plans to offer them at a scheduled clinic at a later date. The Infection Preventionist further stated that in the six months in this role, no vaccine clinic had yet been held, confirming that pneumococcal vaccines had not been offered to these new residents in accordance with facility policy.
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