Inaccurate Medical Record Diagnosis for Psychotropic/Anticonvulsant Medication
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not accurately documenting a resident’s current medical diagnosis in relation to prescribed medication. Medical record review showed a care plan problem dated 12/15/2025 identifying a potential safety risk related to a seizure disorder, supported by a medication order dated 12/02/2025 for Lamotrigine 200 mg daily “for Seizure,” and a psychiatric note dated 01/29/2026 stating the resident was taking Lamotrigine for a diagnosis of Bipolar Disorder. However, the resident’s Diagnosis Report, which listed all active diagnoses, did not include a seizure disorder diagnosis, and staff confirmed there was no diagnosis or medical documentation in the record verifying that the resident had a seizure disorder. This inconsistency between the care plan, medication indication, psychiatric documentation, and the formal diagnosis list resulted in medical records that did not accurately reflect the resident’s current diagnoses.
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