Unsupported Schizophrenia Diagnosis and Antipsychotic Use Without Clinical Documentation
Penalty
Summary
The facility failed to ensure that services met professional standards of quality when it did not have clinical documentation to support a diagnosis of schizophrenia for one resident who was reviewed for unnecessary medications. The resident was admitted with major depressive disorder and later readmitted from a hospital stay, with the hospital discharge summary not listing schizophrenia as a diagnosis. A provider progress note documented that the resident was seen for visual hallucinations and that haloperidol 1 mg every 6 hours as needed was added for continued hallucinations, but the note did not list schizophrenia as a diagnosis. The resident’s active diagnosis list showed schizophrenia, unspecified, as an admitting diagnosis active as of a specified date, with no onset date, and categorized under medical management. The schizophrenia diagnosis was entered into the record by a nurse, who stated she added it based on a medication that lacked a correct diagnosis and believed, but could not confirm, that a physician had given her this information. The resident’s care plan, last revised on a specified date, did not include a care plan for schizophrenia. The MDS quarterly assessment coded the resident for anxiety, depression, and bipolar disorder, but not schizophrenia. Review of the electronic and paper records revealed no clinical documentation supporting schizophrenia. The consultant pharmacist reported that the pharmacy had not requested adding a schizophrenia diagnosis, and a physician stated he had not given or written such a diagnosis and, to his knowledge, the resident did not have schizophrenia. The DON was unable to locate documentation from either physician supporting the diagnosis and only believed that one physician had reported a significant history of schizophrenia, while the Administrator could not recall whether the resident had that diagnosis and indicated she would discuss it with the clinical team.
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