Failure to Provide Timely Follow-Up Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a timely pneumococcal (PNA) vaccination to a resident in accordance with CDC recommendations and its own policy. The resident was admitted on 6/2/2021 with diagnoses including congestive heart failure, chronic kidney disease, and hypertension. Review of the resident’s immunization audit report showed that the resident had received PCV13 (Prevnar 13) on 1/13/2019. However, there was no documented evidence in the clinical record that the resident was offered or received any follow-up PNA vaccine after receiving PCV13. During an interview and concurrent review of CDC PNA vaccine recommendations with the facility’s infection preventionist (IP) on 3/3/2026 at 1:01 p.m., the IP confirmed that CDC recommends one dose of PCV20 or one dose of PCV21 at least one year after a dose of PCV13. The IP acknowledged that the facility did not offer or provide either PCV20 or PCV21 to this resident after the PCV13 dose in 2019, despite this recommendation. Review of the facility’s policy and procedure titled “Pneumococcal Vaccine,” revised March 2022, indicated that all residents are to be offered pneumococcal vaccines and assessed for eligibility prior to or upon admission and when indicated, which was not carried out for this resident.
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