Inaccurate Medical Record Due to Erroneous Schizophrenia Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. The clinical record for this resident included a diagnosis of Schizophrenia, which was added on a specific date and continued to appear in subsequent physician-signed diagnosis reports and order summaries. However, a review of the resident's preadmission screening, neuropsychology assessments, and psychiatric evaluation did not provide evidence of a history of Schizophrenia prior to admission. Despite this, the diagnosis was repeatedly coded as active in multiple Minimum Data Set (MDS) assessments. A departmental progress note documented that, after discussions with the resident, their physician, and family, it was determined that the Schizophrenia diagnosis was a clerical error and that the resident did not have a history of this condition. The Director of Nursing confirmed that there was no evidence supporting the diagnosis in the clinical record, indicating that the inclusion of Schizophrenia was inaccurate and not based on the resident's actual medical history.