Health inspection·November 26, 2024

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on and document not administering a consented pneumococcal vaccine (a vaccine for a bacterial infection that can cause a serious lung, brain, or blood infection) for one out of three residents (Resident 1). Residents Affected - Few This deficient practice resulted in Resident 1 potentially contracting pneumonia (a lung infection). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, abnormalities with gait (a person ' s manner of walking), mobility (the ability to move freely or lack thereof), and dysphagia (difficulty swallowing). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/8/2024, the MDS indicated Resident 1 ' s cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for showering and dressing the lower body and hygiene. During a review of Resident 1 ' s Pneumococcal Vaccine Informed Consent dated 11/3/2024, the consent indicated Resident 1 received information about the benefits and risks associated with the pneumococcal vaccine and gave permission for the vaccine to be administered to him. During a review of Resident 1 ' s Nursing Progress Note dated 11/3/2024, the note indicated Resident 1 had an episode of nausea and vomiting (throwing up). During an interview on 11/26/2024 at 2:57 p.m., with the Infection Preventionist (IP), the IP stated Resident 1 consented to receive the pneumococcal vaccine but since he was sick and vomiting, she decided to hold the vaccine until a later date. The IP stated she did not document in Resident 1 ' s clinical record when she held the vaccine due to medical contraindication (inadvisable due to being unsafe) but should have informed the team the need for follow up later. The IP stated follow up of the administration of pneumococcal vaccine to Resident 1 was important because it would protect Resident 1 against pneumococcal disease and aid in reducing the risk of serious illness and death. During an interview on 11/26/2024 at 3:59 p.m., the Director of Nursing (DON) stated documentation of the vaccine given or not given should occur, and if not given the reasons why it was not given Page 1 of 2 055123 055123 11/26/2024 Beachside Post Acute 3294 Santa Fe Avenue Long Beach, CA 90810

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be documented in the resident ' s clinical record. The DON stated ultimately it is the physician who determines if the vaccine is truly medically contraindicated if a resident is presenting to be sick. During an interview on 11/26/2024 at 4:05 p.m., the Administrator (ADM) stated the Control for Disease and Prevention (CDC) guidelines stated the medical contraindications for the pneumococcal vaccine is flu or respiratory symptoms such as coughing, and in that case the vaccine should be held. The ADM stated there should be a process for follow up later to offer the vaccine because the elderly are compromised (more vulnerable to illness) due to comorbidities (multiple medical conditions). During a review of the facility ' s policy and procedure (P&P) titled Pneumonia Vaccine for Residents, dated 1/2024, the P&P indicated the resident ' s clinical record should include documentation the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal. 055123 Page 2 of 2