Failure to Offer and Document Pneumococcal Vaccinations for Two Residents
Penalty
Summary
The facility failed to follow its immunization policy requiring that each resident be offered a pneumococcal vaccination and that the medical record contain documentation of education and either receipt or refusal of the vaccine. Record review for two residents admitted on 1/22/25 and 6/25/25 showed no evidence in their immunization records of pneumococcal vaccination or declination as of 12/15/25 at 12:35 PM. When the surveyor requested evidence of consent or declination, the DON and ADON/ICP later produced consents that were dated 12/15/25, the same day as the surveyor’s request, and the DON confirmed that these two residents had not been offered the pneumococcal immunization prior to that time. These findings were discussed with the NHA, DON, and ED during the exit conference on 12/16/25 at 3:45 PM, confirming that the required offer and documentation of pneumococcal vaccination had not occurred for the two residents reviewed for immunizations.
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