A facility failed to ensure pneumococcal immunizations were offered and documented for 4 of 5 sampled residents reviewed. Four residents were not current with their pneumococcal vaccines, and the record review found no evidence that the vaccine was administered, offered, or declined. The DON and RN infection preventionist stated immunization information should be in the medical record, and the DON noted one resident reportedly declined at a care conference, but there was no documentation of the discussion.
Failure to Offer Influenza and Pneumococcal Vaccines: The facility did not ensure vaccine offers were carried out per policy for two residents. One resident with dementia and other diagnoses had consented to pneumococcal vaccination, but no pneumonia vaccine was documented in the EHR or WIR. Another resident with intact cognition had consented to influenza vaccination, but no flu vaccine was documented during the season. The DON could not provide evidence that either vaccine was given in accordance with policy.
Failure to Offer Flu and Pneumococcal Vaccinations: The facility did not document offering influenza vaccination to two residents or their representatives, and the DON confirmed the pneumococcal status for those residents was not up to date after reviewing CDC guidance. Records showed prior PPSV23/PCV13 and prior annual flu vaccines, but no evidence that the residents were offered, consented to, or declined the current flu vaccine.
A resident with severe cognitive impairment and a Guardian did not receive the influenza vaccine, and the medical record lacked documentation that the vaccine was offered, refused, consented to, or that education on risks and benefits was provided. The facility policy required annual flu vaccination offers and documentation of education and the resident’s choice, but the DON could not find a signed declination for the flu vaccine during interview.
Outdated pneumococcal vaccination policy and missing documentation of vaccine offer or administration: The facility’s pneumococcal policy was not current with CDC guidance, and one resident had documented consent for the pneumococcal vaccine but no record showing the vaccine was offered, administered, or refused. The ADON/IP confirmed there was no documentation of receipt, and the DON stated he would expect the resident to have been offered or given the vaccine after consent was obtained.
A resident signed consent for both pneumococcal and influenza vaccines, but surveyor record review found no documentation that either vaccine was given. The DON stated vaccines are usually administered within a couple of weeks after consent, but could not explain why the resident did not receive them or provide additional documentation.
A resident with dementia and severely impaired cognition signed consent for influenza and pneumococcal vaccines, but the record did not show either vaccine was administered. Facility policy required signed consent before vaccine administration, and both the IP and RNM acknowledged there was no documentation that the vaccines were given.
A resident with ESRD on dialysis, type 2 DM, asthma, and chronic respiratory failure requested the flu vaccine, and the chart documented consent for flu and COVID vaccines. Surveyors found no record that the resident was offered, declined, or received the flu shot, and the DOO confirmed the resident wanted the flu vaccine but did not receive it.
Failure to Offer and Document Pneumococcal Immunization: A resident admitted with an activated HCPOA had no documentation that the pneumococcal vaccine was ever offered, received, or declined. The facility policy required immunizations to be reviewed on admission and documented in the EMR, but the DON stated the facility did not have vaccine consent or declination forms, and the CNC later confirmed the vaccine should have been offered or declined at admission.
Failure to Offer Prevnar 20 Pneumococcal Vaccination: The facility did not offer Prevnar 20 to 3 of 5 sampled residents who were eligible based on their vaccine history and CDC guidance. The residents had diagnoses including diabetes, AFib, pneumonia, dementia, HF, and occipital neuralgia, with intact cognition documented by BIMS scores and activated POAHCs. Their records showed prior Pneumovax 23 and PCV13 vaccines, but no documentation that Prevnar 20 was offered or given; the DON confirmed each resident should have been offered the vaccine.
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