F0658

D

Lack of Supporting Documentation for New Schizophrenia Diagnoses

Joliet, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that new diagnoses of paranoid schizophrenia for two residents were supported by documented clinical findings in the medical record. For one resident, a middle‑aged female admitted with bipolar disorder and alcohol abuse, the face sheet showed that generalized anxiety disorder and later paranoid schizophrenia were added as diagnoses. Her MAR reflected a long‑standing order for quetiapine 300 mg at bedtime for bipolar disorder, which was discontinued and then reordered at the same dose and time for the new diagnosis of paranoid schizophrenia. Behavior monitoring was ordered daily on all shifts for more than 15 months, yet the MAR behavior tracking sections showed no documented observations of withdrawal, depression, false beliefs, hallucinations, paranoia, delusions, or mood changes during that entire period.

During interviews and record review for this resident, staff and providers described minimal or no psychotic‑type behaviors. The psychiatric NP’s follow‑up note on the date the schizophrenia diagnosis was added documented that the resident was well‑groomed, appropriate, calm, with clear speech, linear thought processes, intact associations, and an upset mood, and that she was being seen for medication management. The resident reported that the NP told her quetiapine and clonazepam might be stopped because of rule changes and that she would need a diagnosis of paranoid schizophrenia to continue the medication. The DON stated that residents on psychotropics or with behavioral health diagnoses receive behavior monitoring, and that all behavior monitoring should be documented in the medical record, including progress notes, MAR behavior templates, and therapy/psychiatric reports. However, nursing, CNA, and social services staff reported only anxiousness and excitability for this resident and denied observing hallucinations, paranoia, or delusions, and there was no behavior documentation supporting the new schizophrenia diagnosis.

For the second resident, an older female admitted with multiple psychiatric diagnoses including dementia with behavioral disturbance, bipolar disorder, delusional disorder, recurrent major depressive disorder, generalized anxiety disorder, and shared psychotic disorder, the face sheet showed that paranoid schizophrenia was added as a new diagnosis. Her care plan and physician orders included behavior tracking for depression, withdrawal, false beliefs, hallucinations, paranoia, delusions, and mood changes. Review of MARs over several months showed no documented behavioral symptoms of withdrawal, false beliefs, hallucinations, paranoia, or delusions across all shifts. Social services staff stated they had not observed delusions, hallucinations, or paranoia in this resident and described her as primarily anxious and concerned about her health and dementia, with a habit of writing things down. The psychiatric physician explained that a schizophrenia diagnosis requires at least two core symptoms (such as delusions, hallucinations, disorganized thoughts/behaviors, or paranoia) over a prolonged period and emphasized the need for contemporaneous documentation of observed symptoms, which was not present in these residents’ records to support the new schizophrenia diagnoses.