Inaccurate Documentation of Psychiatric Diagnosis in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident diagnosed with schizoaffective disorder. Documentation inconsistencies were found in the resident's medical record, with some parts inaccurately listing schizophrenia as the diagnosis instead of schizoaffective disorder. The resident's face sheet and several clinical assessments correctly identified schizoaffective disorder, but the care plan, physician orders, and some nurse practitioner notes referenced schizophrenia. The discrepancy was confirmed during interviews with the DON and NP, who acknowledged that the original diagnosis was schizoaffective disorder, but schizophrenia had been documented in various parts of the record, including the care plan and medication orders. This documentation error resulted in the resident's clinical records not being maintained in accordance with accepted professional standards and practices. The resident, who had a history of paraplegia, mood disorder, and schizoaffective disorder, was receiving antipsychotic medication (Risperdal) for her condition. The inaccurate documentation could affect the appropriateness of care provided, as the care plan and medication orders were not aligned with the resident's actual diagnosis as established by the primary care provider.