Unsubstantiated Schizoaffective Disorder Diagnosis and Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality when assigning a new diagnosis of schizoaffective disorder and initiating an antipsychotic medication for one resident without adequate supporting assessment or documentation. The resident’s clinical record showed existing diagnoses of Alzheimer’s disease, depression, borderline personality disorder, and delusional disorder, with prior PASSAR and admission MDS assessments reflecting depression and dementia/Alzheimer’s disease, and treatment with an antidepressant. Nursing progress notes over several months documented episodes of the resident reporting men causing trouble, believing a man was in her room, and talking about a man wanting to marry her and yelling through the walls, as well as frequent refusals of medications, blood sugar checks, blood pressure checks, insulin, and hygiene care. Additional nursing documentation described the resident as sometimes yelling at staff, being visibly upset by a room move, being leery of staff and asking to see name badges, and making statements that housekeeping had not cleaned her room or that she had not received medications when records indicated that she had. Despite these behaviors and delusional-type statements, there were no other documented behaviors in the nursing progress notes between late April and mid-July beyond refusals of care, expressions of dissatisfaction, and intermittent suspiciousness. The record did not contain a comprehensive psychiatric evaluation establishing that the resident had experienced a major mood episode of uninterrupted duration or otherwise met the diagnostic criteria for schizoaffective disorder. On a psychiatric NP visit for initial psychotropic medication management, the NP added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel 25 mg. The resident had no prior history of schizoaffective disorder, and the clinical record lacked an assessment to substantiate this new diagnosis. There was also no documentation that the resident’s mental health history was reviewed with the resident’s representative or that the delusional symptoms were evaluated as a possible progression of Alzheimer’s disease. The resident’s representative later reported that the resident had no known history of mental health disorders or psychiatric hospitalization and was unaware of the schizoaffective disorder diagnosis. The DON stated there was no facility policy specific to schizoaffective disorder and that the facility followed federal regulations.
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