Lack of Documented Evidence-Based Diagnosis for Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided, specifically psychotropic medication management, met professional standards of quality for one resident. The resident’s face sheet and medical diagnoses listed schizoaffective disorder (F25.9), and the care plan included administration of psychotropic medications, including Olanzapine, for this diagnosis. Physician orders and a signed consent for antipsychotic treatment documented that Olanzapine 2.5 mg PO BID was prescribed and administered for schizoaffective disorder, and a gradual dose reduction (GDR) was noted. However, review of the resident’s electronic health record revealed no documentation of a comprehensive assessment or diagnostic workup supporting the schizoaffective disorder diagnosis. Staff interviews confirmed the absence of required diagnostic documentation. The DON stated that the facility did not have a comprehensive assessment diagnosing the resident with schizoaffective disorder, and the ADM similarly acknowledged that there was no comprehensive assessment in the record. Despite this, the resident continued to receive antipsychotic medication for schizoaffective disorder as a listed diagnosis. The facility’s own policy on comprehensive, person-centered care plans required that care plans reflect currently recognized standards of practice, but the documentation did not demonstrate that evidence-based criteria had been used to establish the psychiatric diagnosis. Observations and interviews described the resident’s behavior and functioning over time, including initial isolation, limited participation in activities, and later increased activity and reduced aggression, as reported by nursing staff and leadership. The PHY reported that the resident had sleep and depression issues, paranoid behaviors, hallucinations, and agitation for several weeks and stated that he based the schizoaffective disorder diagnosis on these symptoms and his knowledge of the resident. The PHY acknowledged he did not use a comprehensive assessment and that supporting documentation for the diagnosis was not present in the facility’s record at the time of review. This lack of documented, evidence-based diagnostic assessment in the medical record, despite ongoing antipsychotic treatment for schizoaffective disorder, constituted the cited failure to meet professional standards of quality and to align the care plan with recognized standards of practice.
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