Inaccurate MDS Completion for Resident's Pneumococcal Vaccine Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident, who was admitted with a diagnosis including a urinary tract infection, had a quarterly MDS indicating intact cognitive functioning and that the pneumococcal vaccine was offered and declined. However, upon review, there was no documentation in the electronic medical record or hard chart regarding the pneumococcal vaccine. This discrepancy was identified during a surveyor's review of the resident's records. The Director of Nursing (DON) stated that vaccine acceptance, refusal, and education are documented in the resident's records, but this was not found for the resident in question. The MDS Coordinator, upon being questioned, was unable to locate the resident's information and later admitted that the MDS needed correction to reflect that the pneumococcal vaccine was not offered. The facility's policy on pneumococcal vaccination requires documentation of vaccination history and education, which was not adhered to in this case.
Plan Of Correction
1. Corrective Action of Areas Affected: The MDS Coordinator has reviewed and corrected the MDS for Resident #41 to accurately reflect the [R] status. 2. Other Areas Affected: All residents have the potential to be affected by the deficient practice. 3. Systemic Changes to Prevent Future Occurrences: DON/Designee has re-educated the MDS department on the accurate documentation of vaccine offerings, acceptances, and refusals. An initial house wide audit has been completed for accurate reflection of pneumococcal vaccination status in the MDS assessment. 4. Monitoring of Corrective Action: DON/Designee to conduct monthly audits x 4 of MDS assessments completed during that month for MDS accuracy of pneumococcal vaccination. Results of the audits to be reviewed at the facility's monthly Quality Assurance Improvement Meetings.