Failure to Accurately Document Depression Diagnosis in Resident Assessment
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's assessment accurately reflected their current medical status. The resident in question had a documented history of severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit. Multiple psychiatric and nursing notes, as well as physician orders, indicated that the resident was being treated for depression with escitalopram (Lexapro), and the diagnosis of depression was referenced in several clinical documents. Despite this, the resident's medical diagnoses list and the Quarterly Minimum Data Set (MDS) did not include depression as a diagnosis. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's depression diagnosis. Registered nurses and the social service worker were either unsure or unaware of the depression diagnosis, and the face sheet did not reflect it. The Director of Nursing confirmed that the resident had been diagnosed with depression, but this information was not updated in the medical chart or the MDS, resulting in an inaccurate assessment of the resident's condition.