| 185 |
ST. BARBARA'S MEMORIAL NURSING HOME |
515012 |
PO BOX 9066 |
FAIRMONT |
WV |
26555 |
2018-09-27 |
865 |
E |
0 |
1 |
DL7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's quality assurance and performance improvement program (QAPI) / quality assessment and assurance (QAA) committee failed to identify and implement corrective action for quality deficiencies for which they should have been aware of to improve the lives of the residents. The facility failed to ensure that 10 out of 13 residents either received the appropriate pneumococcal immunization, or did not receive the pneumococcal immunization due to medical contraindication or refusal. These practices had the potential to affect more than a limited number of residents at the facility. Resident Identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's compliance guidelines indicate the residents medical record must include documentation that indicates the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. c) Centers for Disease Control (CDC) guideline for Pneumococcal Vaccine Timing for adults [AGE] years or older state for those who have not received any pneumococcal vaccines, or those with unknown vaccination history, administer 1 dose of 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) then administer 1 dose of 23-valent pneumococcal [MEDICATION NAME] vaccine ([MEDICATION NAME] 23, PPSV23) at least one (1) year later for most immunocompetent adults or at least eight (8) weeks later for adults with immunocompromising conditions. For those who have previously received 1 dose of PPSV23 at age [AGE] years or older and no doses of PCV13, administer 1 dose of PCV13 at least one year after the dose of PPSV23 for all adults, regardless of medical conditions. d) Review of facility's immunization report documentation dated (MONTH) 26th, (YEAR) reveals no documentation of refusal or administration of the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) for residents #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. e) These findings were shared on 09/27/18 at 1:10 PM with the Administrator #12 and she stated, We were not aware that we need to offer the Prevnar 13 (13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13), we have ordered it. No further information regarding the immunization process was provided by the facility prior to exit. |
2020-09-01 |