F0883

D

Failure to Administer Indicated Pneumococcal Vaccine per CDC Guidelines

Shoreline, Washington Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that pneumococcal vaccination was up to date for one resident in accordance with its own policy and current CDC recommendations. The facility’s pneumococcal vaccine policy, dated October 2025, required that all residents be offered pneumococcal vaccines and that administration follow current CDC guidelines. CDC’s Adult Immunization Schedule Notes indicated that an adult who had previously received both PCV13 and PPSV23, but had not received PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose. Record review showed the resident had received PPSV23 on 02/14/2001 and PCV13 on 11/12/2018, meeting criteria for an additional pneumococcal vaccine dose.

Further review of the resident’s records showed that on 03/10/2024 the resident had signed a Vaccination History and Consent form agreeing to receive Prevnar 20 (PCV20). However, review of the electronic health record did not show any documentation that Prevnar 20 was administered. During an interview and joint record review, the Infection Preventionist confirmed that the facility followed CDC guidelines, acknowledged the signed consent for Prevnar 20, and stated there was no documentation that the vaccine had been given. The DON also stated the expectation that the resident would have received the pneumococcal vaccination per CDC guidelines. This lack of administration and documentation for the agreed-upon and indicated pneumococcal vaccine constituted the deficiency.