F0883

D

Failure to Administer Indicated Pneumococcal Vaccination After Consent and Policy Requirements

Buffalo, Wyoming Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was immunized for pneumococcal disease in accordance with its own policies and current CDC recommendations. Medical record review showed the resident’s most recent Pneumococcal Conjugate Vaccine (PCV13) was administered on 10/18/19, and the facility documented a plan to administer Prevnar 20 at the time of admission in July 2025, but there was no record that this vaccine was actually given. A vaccine consent form dated 7/9/25 showed the resident had consented to receive the pneumonia vaccine. In an interview on 1/23/26 at 10:00 AM, the Infection Preventionist confirmed the resident did not receive the planned vaccine. The facility’s written policy, dated 12/2023, required that veterans be assessed for eligibility for the pneumococcal vaccine series prior to or upon admission and, when indicated, be offered the vaccine series within 30 days of admission, with administration to follow current CDC recommendations. CDC guidance in effect at the time stated that adults over a specified age who previously received one dose of PCV13 should receive one dose of PCV20 or PCV21 at least one year after the last PCV13 dose, which had not occurred for this resident.