Inaccurate MDS Documentation of Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the pneumococcal vaccination status of eight residents. The Resident Assessment Instrument (RAI) User's Manual provides specific coding instructions for documenting a resident's pneumococcal vaccination status. However, discrepancies were found between the residents' informed consent forms and the MDS records. For instance, Resident R30 refused the pneumococcal vaccine, but the MDS indicated the vaccine was not offered. Similarly, Residents R43, R54, R56, R64, R69, and R70 consented to receive the vaccine, yet their MDS records inaccurately stated that the vaccine was not offered. The Licensed Practical Nurse Assessment Coordinator confirmed that the MDS assessments were not completed accurately. This inconsistency in documentation suggests a failure in the facility's process for ensuring accurate and up-to-date resident assessments, as required by the regulations. The inaccuracies in the MDS records could potentially impact the care and treatment plans for the residents involved.
Plan Of Correction
1. R30, R43, R54, R56, R64, R66, R69, and R70 were reviewed and updated to reflect current resident status. 2. MDS/Designee will review MDS house audit accuracy for Pneumococcal vaccinations. 3. MDS/Designee will develop, educate, and implement a standardized communication protocol between the infection preventionist and the MDS staff to ensure all relevant health information, including vaccination status and offerings, is accurately communicated and recorded. 4. A weekly times two, then monthly times two audit of MDS assessments to verify accuracy and completeness, with a specific focus on health prevention measures pneumococcal vaccinations. 5. Will begin immediately, with ongoing monthly audits for at least two months. 6. Audit results will be reviewed during monthly QAPI meetings, and findings will be documented.