Inaccurate Resident Diagnoses Documented in Medical Record
Penalty
No penalty information released
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Summary
The facility failed to ensure the accuracy of a resident's medical record by listing incorrect diagnoses. Review of the clinical record for one resident showed diagnoses of schizophrenia and bipolar disorder, as well as a cognitive communication deficit. The resident information sheet, last reviewed by the physician, also included schizophrenia and bipolar disorder. However, physician's orders did not include any antipsychotic medications for these conditions. During interviews, the DON confirmed that the resident did not have schizophrenia or bipolar disorder and acknowledged that these diagnoses were incorrectly listed. Additionally, the facility was unable to provide an accurate records policy upon request.