F0883

D

Failure to Properly Offer and Document Pneumococcal Vaccinations

Decatur, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly offer and administer pneumococcal vaccinations to two residents reviewed for immunizations. One resident had a Minimum Data Set (MDS) indicating moderately impaired thought processes and stated she did not remember being asked about the pneumonia vaccine at admission, but expressed that she would like to receive it if offered. Her family member and POA, who was present at admission, recalled the facility offering influenza and COVID-19 vaccines but not the pneumonia vaccine, and also stated it would be beneficial for her to receive the pneumonia vaccine. The resident’s Authorization and Release for Vaccinations form was marked as a refusal to sign but was undated.

Another resident, whose MDS documented intact thought processes, reported not recalling that the pneumonia vaccine was offered at admission. She stated that the facility had offered influenza and COVID-19 vaccines during the current year but not the pneumonia vaccine, and that she would like to receive the pneumonia vaccine if available. The LPN Admissions Coordinator stated that she educates residents and families about the vaccine program at admission and reported that the first resident declined the pneumonia vaccine on a specific date, acknowledging that the refusal form should have been dated. The DON stated that simply asking residents on admission whether they want the pneumonia vaccine is not sufficient. The facility’s written Pneumococcal Vaccine Program policy requires staff to follow a protocol to determine eligibility upon admission, discuss recommendations with the physician when needed, and document education and refusals in the medical record, including when immunization is refused.