Failure to Accurately Document Resident's Mood Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that an accurate medical diagnosis was documented for one of three sampled residents by not reflecting a diagnosis of adjustment disorder with depressed mood in the resident's records. The resident in question was admitted and readmitted with several medical diagnoses, including hypertension, hyperlipidemia, diabetes mellitus, and glaucoma. However, despite psychiatric and psychologist consultation notes indicating a diagnosis of adjustment disorder with depressed mood and a history of major depressive disorder, this diagnosis was not included in the resident's admission record or in the active diagnoses section of the Minimum Data Set (MDS). The MDS assessment indicated that the resident had moderate cognitive impairment and required varying levels of assistance with self-care activities. The resident was also taking an antidepressant medication, yet the corresponding mood disorder diagnosis was missing from the MDS. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the diagnosis should have been documented in the resident's medical records to ensure care planning, monitoring, and appropriate treatment. Both staff members acknowledged the importance of accurate and up-to-date diagnoses for effective care and to prevent confusion. A review of the facility's policy on resident assessment and documentation showed that comprehensive and accurate assessments are required, with findings to be documented in the clinical health record. The failure to document the resident's adjustment disorder with depressed mood resulted in an incomplete and inaccurate reflection of the resident's condition in the medical record, which could impact the provision of necessary care and services.