F0841

E

Failure of Medical Director Oversight for Infection Control, Informed Consent, and Serious Mental Illness Diagnoses

Napa, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of the designated medical director, Physician R, to effectively participate in and oversee resident medical care, including infection prevention and control, informed consent for psychotropic medications, and appropriate diagnostic evaluation for serious mental illness. Surveyors determined that the Infection Prevention and Control Program for a census of 116 residents did not receive oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases, including measures designed to slow and prevent the spread of C. difficile and to address waterborne illness risks related to positive Legionella results. This lack of medical director oversight was cross-referenced to F880.

For informed consent, the facility’s own policy titled “Psychotropic: Medication Use,” revised 02/25, required that prior to initiating, increasing, or switching psychotropic medications, staff and the physician review non-pharmacological alternatives, indications and rationale, potential risks and benefits (including side effects, adverse consequences, and black box warnings), and the resident or representative’s right to accept or decline treatment. Record review showed that Resident 12 had an informed consent form dated 3/16/25 for Risperidone for visual hallucinations that was not signed by the resident’s representative and did not indicate verbal consent. A second informed consent form dated 9/11/25 for Mirtazapine for depression and Risperidone for visual hallucinations was also not signed by the representative and did not indicate verbal consent. Resident 10’s representative reported never hearing from the medical doctor and not signing any forms concerning psychotropic medications, stating she felt she was not kept informed. Resident 12’s representative stated she had not spoken to anyone about psychotropic medications and would have declined them because she felt they made Resident 12 less functional. The DON stated her expectation was that Physician R would contact representatives for education and treatment planning before nurses obtained confirmation and signatures, and she was surprised the representatives had not heard from him. In contrast, Physician R stated he could not do all the education and depended on nurses to teach and notify him if representatives had concerns.

The deficiency also included inadequate diagnostic evaluation for new diagnoses of serious mental illness, specifically schizophrenia and schizoaffective disorder, for two residents. Resident 10 was admitted with dementia, major depressive disorder (MDD), and unspecified psychosis, and had severe cognitive impairment per an MDS dated 12/22/25. Her physician order summary listed Seroquel for schizoaffective disorder manifested by visual hallucinations. However, a CHE Behavioral Health psychiatry note dated 9/13/23 listed active diagnoses of dementia and MDD with no auditory hallucinations, and a SOAP note by Physician R dated 10/12/23 listed no new diagnosis of schizoaffective disorder. On 10/16/23, facility staff faxed Physician R noting Resident 10 was taking Seroquel without an assigned diagnosis and requested an updated diagnosis list; schizoaffective disorder was added that same day by Physician R. Subsequent CHE psychiatry notes, including 12/27/23 and 12/24/25, continued to list dementia and MDD, recommended a Seroquel dose decrease, and did not mention schizoaffective disorder. The DON stated a serious mental illness diagnosis should not be added solely for medication and should be properly diagnosed by behavioral health, and that mislabeling could inappropriately label residents. Resident 10’s representative stated the resident had no history of schizoaffective disorder and she had never spoken to a medical doctor about this diagnosis. Physician R stated residents with schizoaffective disorder are referred to psychiatry and, if psychiatry did not confirm the diagnosis, it should have been removed; he further stated he may have added the diagnosis based on evolving symptoms.

Resident 2’s record showed admission with cerebral infarction with right-sided weakness, epilepsy, diabetes, anxiety, and psychotic disorder with delusions. On 2/6/24, a schizophrenia diagnosis was entered. A behavioral health note dated 11/29/23 by NP LL recommended starting Risperdal 0.25 mg daily for delusions and paranoia but did not list schizophrenia. Review of physician and behavioral health notes from November 2023 through May 2024 revealed no mention of schizophrenia. NP KK, from the behavioral health group, confirmed that NP LL’s notes did not mention schizophrenia at the time Risperdal was prescribed and that her own December 2024 note was the first documentation of schizophrenia as a diagnosis. A fax dated 2/6/24 from MDS Nurse NN to Physician R asked if the diagnosis list could be updated to include schizophrenia for a resident on Risperdal; Physician R responded “Yes” with his signature. NP KK stated the schizophrenia diagnosis was based on delusions, a BIMS score of 3, and symptom improvement on Risperdal. Psychologist MM, Resident 2’s psychologist, stated his notes documented a delusional disorder, not schizophrenia, and that the two diagnoses are not interchangeable; his progress notes did not mention schizophrenia. MDS Nurse NN stated she sent the fax because the MDS system required a matching diagnosis for the antipsychotic and that she was not aware of any clinician documentation diagnosing schizophrenia at that time. MDS Nurse OO similarly stated there was no documentation that a clinician had diagnosed schizophrenia when the diagnosis was entered in February 2024. The facility’s “Schizophrenia and Related Disorders – Clinical Protocol,” revised 3/2025, required that practitioners not newly diagnose serious mental illness without evidence-based criteria documented in the record, including comprehensive assessment findings, DSM-consistent symptoms and duration, exclusion of other causes, and documentation of the effect on function. These requirements were not met in the documentation surrounding the new schizophrenia diagnoses for Residents 2 and 10.