Inaccurate Documentation of Resident Diagnosis in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were accurately documented and complete for one of three sampled residents. Specifically, a resident was admitted with a history of dementia and a past episode of depression, but the face sheet incorrectly listed major depressive disorder as a current diagnosis. Review of the psychiatrist's progress notes and the history and physical indicated that the resident did not have an active diagnosis of depression and was not prescribed psychiatric medication at the time. The Minimum Data Set (MDS) assessment also did not indicate an active diagnosis of major depressive disorder. Interviews with the DON and review of documentation revealed that the depression diagnosis was historical and not current, and the listing of 'recurrent depression' was identified as a typographical error. The DON clarified that the resident only had a history of depression and was not currently exhibiting symptoms or receiving treatment for depression. The facility's documentation policy required relevant findings to be accurately recorded in the clinical record, but this was not followed in this instance, resulting in incomplete and inaccurate medical records for the resident.