Failure to Document Pneumococcal Vaccination Status in Medical Records
Penalty
Summary
The facility failed to document the pneumococcal vaccination status for two residents in their medical records. Both residents had significant cognitive impairments and required varying levels of assistance with daily activities, as indicated by their Minimum Data Set (MDS) assessments. A review of their face sheets and MDS confirmed their diagnoses, including dementia, diabetes, and hypertension, and outlined their dependence on staff for personal care. However, upon examination of their medical records, there was no documentation of their pneumococcal vaccination status. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the vaccination status for these residents was not recorded in the medical records. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, but this standard was not met in these cases.