Failure to Offer Recommended Pneumococcal Vaccination Options
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of pneumococcal vaccination practices for one resident. The resident, over 65 years of age at the time of admission on 08/09/23, had documentation in the electronic medical record (EMR) under the Preventive Health section showing receipt of PPSV23 on 08/18/23. However, there was no evidence in the clinical record that the resident or the resident’s representative participated in shared clinical decision-making regarding the option to receive an additional pneumococcal vaccine dose with PCV15, PCV20, or PCV21 after the PPSV23 vaccination. During an interview on 12/12/25, the Infection Preventionist confirmed that she missed offering this resident the PCV15, PCV20, or PCV21 vaccination. Review of the facility’s Resident Vaccination Policy dated 03/04/25 showed that it required staff to ask residents or responsible parties about prior vaccinations at admission and to document prior pneumococcal and other vaccines in the immunization portal of the EMR. However, the policy did not include the CDC recommendations for pneumococcal vaccinations, which state that, based on shared clinical decision-making, adults 65 years or older who have received PCV13 and PPSV23 at or after a specified age may opt to receive PCV20 or PCV21 or decline additional pneumococcal vaccines. The absence of documentation of shared decision-making and the missed offer of PCV15, PCV20, or PCV21 for this resident constituted the identified deficiency.
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