I assume by now everybody is frantically auditing their resident’s charts for one word (or a derivative of it): schizophrenia! Because you might be audited for the inappropriate use of antipsychotics. 

To be honest, we may have gotten ourselves in this mess. We can’t deny that some residents were coded as having a diagnosis of schizophrenia to have them excluded from the quality measure related to long stay residents receiving an antipsychotic.

Now, I will first say that the Centers for Medicare & Medicaid Services did set us up for failure. Schizophrenia, Tourette’s and Huntington’s disease are the only three diagnoses that are excluded from this QM. (Now could it be that at the time this regulation was updated the second-generation antipsychotics were costing Medicare a bundle? Nahhhhhhhh!) 

But I ask: What about bipolar disorder, explosive disorder or general psychosis, for example? Aren’t those disorders often treated with antipsychotics? Long-term care has become a place for people with multiple chronic clinical comorbid conditions overlayed with behavioral issues. And many of us have facilities that house a 100% behavioral health population. Also, what about psychosis of Parkinson’s disease or behavioral psychosis of dementia (BPD) where hallucinations (both auditory and visual), delusions, aggression, agitation and severe paranoia are common? 

Let’s face it, there is a legitimate reason many residents need antipsychotics beyond schizophrenia, Tourette’s and Huntington’s disease. But we have to be honest with our documentation and rationale. I do not believe the intent is to stop residents from getting medication they need. And yes, our QM will be affected but the most important thing is the best outcomes for our residents.

So back to our frantic audits. This is where we have to be extra careful. First, it is rare that someone over 59 years old suddenly gets schizophrenia. Schizophrenia, on average, is diagnosed in the mid-20s to the mid-30s. So look for that diagnosis added after the resident was admitted. Target those first. 

Second, you can’t have a practitioner at your facility just document that the resident is hallucinating and therefore is schizophrenic. (As I pointed out, that could be BPD). You can have a practitioner suspect schizophrenia and then refer the resident to psychiatry. We can speak to the family and see if there was this behavior earlier in life and are there any behavioral health records. The important thing here is that proper diagnoses must come from a psychiatric health provider. 

Any resident on an antipsychotic needs psych services, period. There are wonderful, competent virtual providers you can contract with even if you are in the most remote area. If you admit someone who does have a history of schizophrenia, find out who saw them on the outside and get some back-up documentation. Just letting your current general practitioner (even if that practitioner is also your medical director) give you a psych diagnosis  isn’t going to cut it. It’s like letting your attending do a surgical removal of an appendix, and that’s just crazy! 

This enforcement is serious. You can go from a 5-star facility to a 1-star in a heartbeat. And that’s no joke.

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, Senior Director of Clinical Innovation and Education for Mission Health Communities, LLC and an APEX Award of Excellence winner for Blog Writing. Vance is a real-life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates. 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.