Failure to Document PCV20 Offer or Declination for a Resident
Penalty
Summary
The facility failed to offer and administer, or obtain an informed declination for, the Pneumococcal Conjugate Vaccine (PCV20) for one resident in the sample. Record review for Resident 3 showed prior pneumococcal vaccinations (PCV13 on 10/30/15 and PPSV23 on 11/12/04), but the clinical record lacked documentation that PCV20 was offered or declined, lacked documentation of a historical administration of PCV20, and lacked any physician-documented contraindication. According to Administrative Nurse D, the admitting nurse was responsible for ensuring the resident or family signed a consent or declination for immunizations, with the signed form to be uploaded into the resident’s chart; however, Administrative Nurse D was unable to locate the consent or declination for this resident and stated that the room where the forms had been stored had flooded. The facility’s Immunizations-Pneumococcal policy required that, at admission, the nurse determine the resident’s vaccination history through resident, family, or primary care provider information and document it on the immunization record, but this required documentation for PCV20 was not present in the resident’s record. The deficiency was identified during a review of a census of 51 residents, with a sample of 14 residents and five reviewed for immunization status, and was based on the missing documentation and interviews confirming that the required consent/declination and immunization record for PCV20 were not available in the resident’s chart.
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