Failure to Document Mood Disorder Diagnosis in Resident Record
Penalty
Summary
The facility failed to document a resident's diagnosis of mood disorder in the admission record, despite evidence from multiple sources indicating the presence of this condition. The resident was admitted with several diagnoses, including chronic respiratory failure and quadriplegia, but the admission record did not reflect a mood disorder. However, the Minimum Data Set assessment and medical professional progress notes indicated the resident had intact cognition and was dependent on staff for certain activities, and a psychiatrist had planned to initiate Depakote for mood disorder. The order summary report showed an active physician order for Depakote, but the order did not specify the diagnosis of mood disorder, only referencing poor impulse control manifested by screaming and yelling. During an interview, the DON confirmed that Depakote was prescribed for a mood disorder and acknowledged that the admission record should have been updated to include this diagnosis. The facility's policy required that psychotherapeutic medication orders include the diagnosis and indications for the medication, which was not followed in this case. This omission meant that the resident's current condition and the justification for the medication were not clearly documented or communicated to staff.