Other·May 8, 2024

Villa Siena F883 The following reflects the findings of the California Department of Public Health during a recertification survey. Event ID: 5D8B11 Representing the Department, HFEN # 44733 State Citation B was written §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. On 4/15/24 at 8:30 a.m., an unannounced visit was conducted at the facility for a recertification survey. The facility failed to follow their policies for influenza vaccine (known as flu shot, immunization against infection by influenza viruses) and pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) when the facility did not offer pneumococcal vaccinations and influenza vaccinations in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations to 22 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, 27, and 181). This failure had the potential to put the residents at risk of acquiring pneumococcal and influenza infections. Findings: 1. Review of Resident 2's face sheet indicated that the resident was admitted on 11/29/21. Review of Resident 6's face sheet indicated that the resident was admitted on 8/21/20. Review of Resident 7's face sheet indicated that the resident was admitted on 7/30/19. Review of Resident 9's face sheet indicated that the resident was admitted on 10/18/21. Review of Resident 12's face sheet indicated that the resident was admitted on 10/24/23. Review of Resident 15's face sheet indicated that the resident was admitted on 8/23/17. Review of Resident 27's face sheet indicated that the resident was admitted on 2/02/24. Review of Resident 181's face sheet indicated that the resident was admitted on 3/19/24. Review of the immunization list provided by the facility on 4/19/24 indicated there was no documentation of Resident 2, 6, 7, 9, 12, 15, 27, or 181's pneumococcal vaccination status. During an interview and record review on 4/19/2024 at 2:51 p.m. with the Director of Nursing (DON), she stated she could not locate any documentation of Resident 2, 6, 7, 9, 12, 15, 27, or 181's pneumococcal vaccination status. The DON acknowledged that the facility should have tracked the pneumococcal vaccination record for the residents. The DON confirmed there was no documentation indicating the residents were up to date per the CDC's pneumococcal vaccine recommendations. 2. Review of Resident 3's medical record indicated that the resident was admitted on 8/11/21 and received pneumococcal (not specified) on 10/14/15 and Prevnar13 (PCV13 [Pneumococcal Conjugate Vaccine 13], a type of pneumococcal vaccine) on 10/27/17. Review of Resident 5's medical record indicated that the resident was admitted on 6/23/20 and received Prevnar 13 on 6/01/15 and Pneumovax 23 (PPSV23 [Pneumococcal Polysaccharide Vaccine 23], a type of pneumococcal vaccine) on 10/13/16. Review of Resident 10's medical record indicated that the resident was admitted on 3/08/23 and received PPV23 on 7/15/19. Review of Resident 11's medical indicated that the resident was admitted on 5/08/23 and received PCV13 on 10/2014 and PPSV23 on 3/06/14. Review of Resident 13's medical record indicated that the resident was admitted on 2/01/22 and received PPSV23 on 4/30/13 and PCV13 on 2/04/15. Review of Resident 14's medical record indicated that the resident was admitted on 12/28/21 and received Prevnar (not specified) in 2015 and Pneumovax on an unknown date. Review of Resident 16's medical record indicated that the resident was admitted on 7/12/22 and received PNUPS (pneumococcal polysaccharide vaccine, PPSV) on 9/05/02 and PCV13 on 6/10/17. Review of Resident 18's medical record indicated that the resident was admitted on 12/20/21 and received PPSV23 on 8/15/03 and PCV13 on 11/25/15. Review of Resident 20's medical record indicated that the resident was admitted on 1/27/22 and received PPSV23 on 9/18/1997 and PCV13 on 1/19/15. Review of Resident 21's medical record indicated that the resident was admitted on 4/27/20 and received PCV13 on 11/28/16 and PPSV23 on 11/18/17. Review of Resident 23's medical record indicated that the resident was admitted on 9/13/23 and received PPSV23 on 1/21/08 and PCV13 on 2/23/17. Review of Resident 24's medical record indicated that the resident was admitted on 8/12/22 and received PCV (not specified) on 11/30/00. Review of Resident 25's medical record indicated that the resident was admitted on 4/18/22 and received PCV23 (pneumococcal polysaccharide vaccine, PPSV23) on 1/01/21 and PCV13 on 5/01/16. Review of Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25's face sheets indicated all 13 residents were over 65 years old. Review of Resident 26's medical record indicated that the resident was admitted on 5/19/21 and received PPSV23 on 2/16/21. The resident was less than 65 years old and had diagnoses including type 2 diabetes mellitus (high blood sugar). During an interview on 4/19/24 at 1:10 p.m. with the DON, she confirmed the above medical record review and stated Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25 were eligible for their pneumococcal vaccines. The DON stated the Infection Preventionist (IP) was responsible for the immunization, and the IP did not offer the vaccines to Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25 per the CDC's pneumococcal vaccine recommendations. The DON confirmed Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25 were eligible to receive the pneumococcal vaccine to be up to date per the CDC recommendation, and the facility did not offer the vaccine to them. During an interview on 4/22/24 at 11:42 a.m. with the IP, she confirmed the above medical record review. The IP stated Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25 were eligible for their pneumococcal vaccines, and the facility did not offer the vaccine to them per the CDC's pneumococcal vaccine recommendations. The IP acknowledged that Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25 should have been up to date with the CDC recommendation for pneumococcal vaccine. The IP further stated the facility did not follow their policy of pneumococcal vaccine. Review of the CDC's "Pneumococcal Vaccine Timing for Adults" dated 3/15/23 indicated, "Adults 65 years and older to complete pneumococcal vaccine schedules: If a resident only received PPSV23, then give 1 dose of Prevnar20 (PCV20, the most up to date pneumococcal vaccine) or PCV15 (Prevnar 15, a type of pneumococcal vaccine) at least 1 year after the most recent PPSV23 vaccination. If a resident only received PCV13, then give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. If a resident received PCV13 and PPSV23, then give 1 dose of PCV20 or PPSV23 at least 5 years after the most recent PCV13 or PPSV23. Adults 19-64 years old with chronic health conditions to complete pneumococcal vaccine schedules: If a resident only received PPSV23, then give 1 dose of PCV20 or PCV15 at least 1 year after the most recent PPSV23. [Please refer to the CDC website for complete information]. During a review of the facility's policy and procedure (P&P) titled "Pneumococcal Vaccine," revised 3/2022, the P&P indicated, "All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. 7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination." 3. Review of the immunization list provided by the facility from 9/21/23 to 4/22/24 indicated there was no documentation of Resident 12 or 181's influenza vaccination status. During an interview and record review on 4/22/24 at 11:06 a.m. with the Infection Preventionist (IP), she stated she could not locate any documentation of Resident 181's influenza vaccination status. The IP acknowledged that the facility should have tracked the influenza vaccination record for Resident 181. During an interview and record review on 4/22/24 at 11:50 a.m. with the IP, she stated that Resident 12 refused the influenza vaccine when offered. The IP stated that she could not locate any documentation indicating the influenza vaccine was offered to Resident 12 but declined. The IP acknowledged that the facility should have documented if Resident 12 declined the influenza vaccination when it was offered. During a review of the facility's policy and procedure (P&P) titled "Influenza Vaccine," revised 3/2022, the P&P indicated, "1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. 11. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination." The facility failed to follow their policies for influenza vaccine (known as flu shot, immunization against infection by influenza viruses) and pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) when the facility did not offer pneumococcal vaccinations and influenza vaccinations in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations to 22 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, 27, and 181). This failure had the potential to put the residents at risk of acquiring pneumococcal and influenza infections. This violation had a direct or immediate relationship to the health, safety, or security of the residents.