Failure to Track Pneumococcal Vaccinations in the EHR
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were properly assessed and tracked in the electronic health record for two residents, as required by its Infection Prevention and Control Plan. The policy dated 8/15/25 states that the Infection Preventionist (IP) is responsible for oversight of infection prevention strategies, including vaccinations. For one resident with diagnoses of diabetes, stroke, and seizure disorder, the face sheet showed admission to the facility and the MDS dated 2/9/26 documented these conditions. The resident’s immunization record indicated that a pneumococcal vaccine was not due until 3/26/25, but the facility could not provide documentation in the medical record that the immunization was assessed on that due date. For another resident admitted to the facility with diagnoses of stroke, hemiplegia, and Parkinson’s disease, the MDS documented these conditions, and the immunization record indicated that a pneumococcal vaccine was not due until 4/28/25. As with the first resident, the facility could not provide documentation in the medical record that the pneumococcal immunization was assessed on the identified due date. During interviews, the IP confirmed that there was no documentation of assessment for either resident on their respective due dates, and the Regional Risk staff member confirmed that the facility failed to ensure pneumococcal vaccinations were tracked in the electronic health record for these residents.
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