Failure to Administer Consented PCV20 and RSV Vaccinations
Penalty
Summary
The facility failed to ensure that ordered immunizations were administered for a resident who had consented to receive them. The resident, identified as Resident #108, had an original admission date noted on the face sheet and a most recent admission date of 2/14/2026. Review of consent forms showed that the resident signed consents on 10/28/2025 and again on 10/28/2026 to receive the Pneumococcal (PCV20) and Respiratory Syncytial Virus (RSV) vaccinations. In the electronic medical record, both RSV and PCV20 immunizations were listed as pending with a confirmation date of 10/28/2025. However, review of the physician orders from October 2025 through 2/26/2026 revealed that no physician orders were ever written for either vaccination. Further review of the Medication Administration Records (MARs) for October, November, and December 2025, and January and February 2026 showed no documentation that the PCV20 or RSV vaccines were administered to the resident. The DON confirmed during interview that, despite the signed consents, the resident never received the vaccinations. The DON also reviewed the resident’s progress notes for October and November 2025 and found no documentation that the vaccinations were given or any notation explaining why they were not administered. The DON stated that the vaccinations should have been administered because the resident requested them and signed consent.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.