Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The deficiency involves the facility’s failure to administer a pneumococcal vaccine to a resident who had consented to receive it. The resident, who had severe cognitive impairment per a quarterly MDS, had a documented history of receiving Prevnar 13 (PCV13) in 2016. A 2025 Vaccine Consent Form in the medical record showed that the pneumonia vaccine option was selected and the resident’s responsible party signed consent for the pneumococcal vaccine. However, review of the medical record revealed no documentation that staff had administered a pneumococcal vaccine following this consent. During an interview, the DON, who also served as the Infection Preventionist, stated she was responsible for assessing and administering immunizations for all new admissions and ensuring residents were up to date per CDC guidelines. She reported that current CDC guidelines recommend PCV20 for residents to be up to date and used a CDC algorithm with prior vaccine history to determine vaccine needs. After entering the resident’s prior vaccines, she confirmed the resident should have received PCV20 but could not explain why it had not been administered. In a separate interview, the Administrator stated she expected resident vaccines to be kept up to date and did not know why staff had not administered the PCV20 vaccine to the resident.
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