Inaccurate Resident Diagnosis Documented in Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident diagnoses for one of nine residents reviewed. Specifically, a review of the clinical record for a resident revealed that the diagnosis of anorexia was added on a specific date, but the care plan, last revised several months later, only noted a potential for nutrition and hydration risk due to advanced age, with the resident currently stable nutritionally. An interview with the Director of Nursing confirmed that the anorexia diagnosis was not accurate and was likely used for billing purposes during a practitioner visit, then transcribed into the resident's list of diagnoses in the clinical record. This discrepancy was identified through observation, policy review, clinical record review, and staff interviews.