Lack of Documentation for New Mental Illness Diagnosis with Antipsychotic Use
Penalty
Summary
The facility failed to provide adequate documentation supporting a newly diagnosed mental illness for a resident who was prescribed an antipsychotic medication. The resident, who had a history of stroke and depression, was readmitted and later assessed by a psychiatric nurse practitioner (NP) who noted auditory hallucinations and continued Risperdal, but did not document the basis for a new bipolar disorder diagnosis. The order for Risperdal was entered for bipolar disorder, but the supporting evaluation or rationale for this diagnosis was missing from the medical record. Subsequent psychiatric assessments referenced the bipolar disorder diagnosis, but the origin and justification for the diagnosis were unclear, and the diagnosis appeared to be automatically generated in documentation without direct clinical substantiation. Interviews with psychiatric NPs, the pharmacist, and the Director of Nursing (DON) revealed that the new diagnosis was not communicated to the DON, and there was no evidence that the diagnosis was properly assessed or documented. The pharmacist relied on the presence of the diagnosis in the order without further verification, and the DON was unaware of the new diagnosis, which prevented appropriate updates to the resident's medical record and notifications to relevant staff. The annual MDS assessment also indicated the use of an antipsychotic without a documented attempt at gradual dose reduction or a clinical contraindication, further highlighting the lack of comprehensive documentation and communication regarding the resident's mental health status and medication management.