cms_ID: 51
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 51 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 883 | F | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, it was determined the facility failed to ensure a) implementation of an immunization program to ensure residents' Pneumococcal (bacterial) pneumonia vaccine status were being tracked with receiving or declining the Pneumococcal vaccines PCV 13 and PPSV 23, consistent with current Centers for Disease Control and Prevention (CDC) recommendations, and b) residents who consented to administration of the Pneumococcal vaccinations, received the vaccinations. This is true for 9 of 9 residents (#2, #4, #7, #9, #12, #16, #19, #29, and #30) reviewed for Pneumococcal vaccinations, and had the potential to impact the other 26 residents residing in the facility. These deficient practices placed residents at risk of developing Pneumococcal pneumonia and developing subsequent serious, potentially life threatening, complications. Findings include: The Centers for Disease Control and Prevention (CDC) website, updated 11/22/16, documented recommendations for Pneumococcal vaccination (PCV 13 or Prevnar 13(R), and PPSV 23 or [MEDICATION NAME] 23(R)) for all adults [AGE] years or older: * Adults who were [AGE] years or older, who had not previously received PCV 13, should receive a dose of PCV 13 first, should follow 1 year later by a dose of PPSV 23. * If the patient already received one or more doses of PPSV 23, the dose of PCV 13 should be given at least 1 year after they received the most recent dose of PPSV 23. The facility's policy and procedure Patient Immunization Program dated 4/27/15, documented the facility would ensure all patients were offered appropriate Pneumococcal vaccinations in accordance with recommendations set forth by the Centers for Disease Control (CDC). The facility's policy Pneumococcal Program dated 10/31/17, documented vaccinations were available that could prevent two kinds of pneumonia: Pneumococcal conjugate vaccine (PCV 13 or Prevnar 13) and Pneumococcal [MEDICATION NAME] vaccine (PPSV 23 or [MEDICATION NAME] 23) included the following: * If not previously received, the facility would provide residents the PCV 13 vaccine upon admission. The facility would follow in at least 8 weeks for high risk residents, and in at least 1 year for other residents, with the Pneumococcal PPSV 23. * If a resident was previously vaccinated with either PCV 13 or PPSV 23, then the facility would follow with the alternate immunization upon admission. * Residents should receive both Pneumococcal immunizations in at least weeks apart for high risk residents and in at least 1 year for other residents. * Revaccination of PPSV 23 is recommended in at least 5 years after PPSV 23. The above policy was not followed. Examples include: a) Resident #7 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, [MEDICAL CONDITION] disorder, anxiety, and depression. Resident #7's Quarterly MDS assessment dated [DATE] documented Resident #7 was offered and declined the Pneumococcal vaccination. The facility Vaccine Information Sheet Acknowledgement and Consent dated 10/11/17, documented Resident #7 wanted to receive the Pneumococcal vaccination. Resident #7's record did not contain documentation she received the [MEDICATION NAME] consented to on 10/11/17. The facility Audit Report for Vaccinations dated 6/13/18, documented Resident #7 received the [MEDICATION NAME] (PPSV 23), on 1/1/08. Resident #7's order summary report dated 6/13/18, did not include a standing order for the Pneumococcal vaccination. b) Resident #12 was readmitted to the facility on [DATE] with multiple diagnoses, including pneumonia, anxiety, and depression. An MDS dated [DATE], documented Resident #12 was given the Pneumococcal vaccination. A Vaccine Information Sheet Acknowledgement and Consent dated 10/11/17, documented Resident #12 consented to receiving the Pneumococcal vaccines. The facility Immunization Report dated 6/2/18, documented Resident #12 received a [MEDICATION NAME] (PPSV 23) on 11/1/17. The reason PPSV 23 was administered prior to the PCV 13 vaccine was not documented. c) Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physician order, dated 1/19/16, documented Resident #2 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #2's quarterly MDS assessment, dated 6/6/18, documented Resident #2 was up to date with the Pneumococcal vaccination. Resident #2's signed Vaccine Information Sheet Acknowledgement and Consent, dated 10/11/17, documented he would like to receive the Pneumococcal Vaccine. The form documented Resident #2 was provided with vaccine information on 10/11/17. The consent did not provide the dates the vaccines were administered prior to admission. Resident #2's Immunization Report, date range 6/1/00 -6/30/18, documented a [MEDICATION NAME] dose was provided on 1/1/02. d) Resident #9 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A Physician order, dated 8/6/14, documented Resident #9 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #9's quarterly MDS assessment, dated 4/6/18, documented Resident #9 was offered and declined the Pneumococcal vaccination. Resident #9's signed Vaccine Information Sheet Acknowledgement and Consent, dated 10/11/17, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form documented Resident #9 was provided with vaccine information on 10/11/17. The consent did not document when, or if, the vaccine was administered prior to admission. Resident #9's Immunization Report, date range 6/6/13 -6/30/18, documented a [MEDICATION NAME] dose was administered on 11/6/14. The Immunization Report also documented Resident #9 refused Prevnar 13 but did not document a date of the refusal. e) Resident #19 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #19's Physician order, dated 2/2/18, documented Do not give [MEDICATION NAME] vaccine. Resident #19's quarterly MDS assessment, dated 5/2/18, documented Resident #19 was up to date with the Pneumococcal vaccination. Resident #19's signed Vaccine Information Sheet Acknowledgement and Consent, dated 2/2/18, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form did not document if vaccine information was provided or when, or if, the vaccine was administered prior to admission. f) Resident #30 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Physician order, dated 2/26/18, documented Resident #30 may have [MEDICATION NAME] vaccine if no history of vaccine. Resident #30's quarterly MDS assessment, dated 5/29/18, documented Resident #30 was up to date with the Pneumococcal vaccination. Resident #30's signed Vaccine Information Sheet Acknowledgement and Consent, dated 2/26/18, documented he did not wish to receive the Pneumococcal Vaccine at that time. The form did not document if vaccine information was provided or when, or if, the vaccine was administered prior to admission. g) Resident #29 was admitted to the facility on [DATE], with multiple diagnoses, including chronic [MEDICAL CONDITION] (irregular heart rhythm) and hypertensive (high blood pressure) [MEDICAL CONDITION]. Resident #29's physician orders, active as of 6/13/18, documented (MONTH) have flu shot annually in season. Influenza vaccine 0.5 ml injected IM (intramuscular) annually as [MEDICATION NAME] for influenza and (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #29's Significant Change MDS assessment, dated 5/23/18, documented the Pneumococcal vaccination was up to date. Resident #29's immunization report documented the Pneumococcal vaccine, historical type unknown, was given on 4/18/13. There was no documentation that efforts were made to provide additional doses of the pneumonia vaccine. h) Resident #16 was admitted to the facility on [DATE] with multiple diagnoses, including unspecified [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #16's physician orders, active as of 6/14/18, documented (MONTH) have flu shot annually in season if not allergic to eggs. Influenza vaccine 0.5 ml injected IM (intramuscular) annually as [MEDICATION NAME] for influenza and (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #16's quarterly MDS assessment, dated 4/18/18, documented the Pneumococcal vaccine was up to date. Resident #16's Immunization Report documented the Pneumococcal PPSV 23 vaccine was administered on 1/1/13. There was no documentation that efforts were made to provide additional doses of the pneumonia vaccine. i) Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including heart failure and [MEDICAL CONDITION]. Resident #4's physician orders, active as of 6/15/18, documented (MONTH) have [MEDICATION NAME] Vaccine if no history of vaccine. Resident #4's quarterly MDS assessment, dated 3/22/18, documented the Pneumococcal vaccine was up to date. Resident #4's Immunization Report documented the Pneumococcal vaccine, historical type unknown, was given on 9/30/14. There was no documentation that efforts were made to provide additional doses of pneumonia vaccine. On 6/13/18 at 2:21 PM, RN #2 stated she was unable to show a system in place for tracking immunizations. On 6/13/18 at 3:19 PM, the DON stated residents were admitted to the facility with an order or standing order for immunization. She stated the facility had a check system in place, which was the MDS assessments. | 2020-09-01 |