Inaccurate MDS Documentation of COVID-19 Vaccination Status
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the COVID-19 vaccination status for three out of five residents reviewed for vaccinations. For these residents, the most recent MDS assessments indicated that their COVID-19 vaccinations were not up to date. However, a review of their immunization records showed that they had received the required COVID-19 vaccine doses, with dates documented for each administration. During an interview, the Infection Preventionist confirmed that the residents should have been considered up to date with their vaccinations according to facility policy, and acknowledged that the MDS assessments did not accurately reflect this status.