correction sent for major error - ? RAPs

[glm777, BSN, RN]

Staff nurse completed an annual MDS/Raps with VB2/4 11/16/09

On 11/30 I was looking at the chart and noticed the resident has a trunk restraint that was not coded on the MDS

I sent a correction on 11/30 adding the restraint, which of course produced a whole new set of RAPs - which now includes "Physical restraint" and "falls" in addition to the 13 that triggered initially.

What do I do about these RAPS? The staff nurse initially did them and she did include all the info about the restraint in her RAPs only she forgot to code it on the MDS.

Do I have to re-do ALL the RAPS, date them 11/30 and put them in the chart or can I simply do the ones that differ from the previous set (falls, physical restraint and pressure ulcers - all the others are exactly the same), date them 11/30 and complete the new RAP summary sheet and date it 11/30? Could I then attach it to the correction sheet and put it in the chart with the other set of RAPs?

This is really the first time we have had to correct such a big error on a full MDS.

I'd appreciate some iinput on how other facilities handle this kind of error. Thanks!

[Talino]

this is really the first time we have had to correct such a big error on a full mds.

if by "big error" you and the idcp considers this a "major error", not only will you be doing a correction (modification), you will also need to complete a significant correction of a prior full assessment.

the provider instructions for making automated corrections using the mds p1-17 defines "major error" as...

if an obra assessment has misrepresented the resident's overall clinical status or the care plan derived from that assessment does not suit the resident's needs, then a major error has occurred.

rai manual p5-8...

when a major error is discovered in an assessment after the assessment has been accepted into the state mds database, the facility must complete the following actions to correct the assessment:

1.correct the original assessment,

2.complete a correction request form to modify the assessment,

3.submit the correction record, and

4.perform a significant correction of a prior assessment or significant change in status assessment and update the care plan as necessary

.

since the restraint rap had already been addressed, the error may not be considered "major." likely, the care plan/s also identified the existence of the restraint, and, modifying the overall plan of care is extraneous.

hence, the submitted correction request (modification) suffices. in the original rap summary sheet, enter an addendum to the relevant triggers with today's date (not backdated).