Failure to Conduct Recommended Movement Assessments for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically in the case of a resident with a complex medical history including Bipolar Disorder, PTSD, ADHD, and Anxiety Disorder. The resident was prescribed Olanzapine, an antipsychotic medication, for Bipolar Disorder. A pharmacist's evaluation recommended that movement tests such as the Abnormal Involuntary Movement Scale (AIMS) or DISCUSS be performed initially within 30 days and then at least every six months to monitor for potential side effects like Tardive Dyskinesia, a movement disorder associated with antipsychotic medications. However, a review of the clinical records revealed that these recommended assessments were not conducted for the resident. This oversight was confirmed during an interview with the Nursing Supervisor, a Registered Nurse, who acknowledged the findings. The lack of these assessments indicates a failure by the facility to adhere to the pharmacist's recommendations, thereby not ensuring the resident's drug regimen was free from unnecessary medications.
Plan Of Correction
Resident R50 Abnormal Involuntary Movement Scale (AIMS) assessment has been completed per pharmacist recommendation. DON / Designee will complete an initial audit of residents receiving an antipsychotic to ensure an AIMS assessment is completed. NPE/DON/Designee to re-educate professional nurses to ensure an AIMS assessment is completed for residents receiving antipsychotics. DON / Designee to complete weekly audits X 4 then monthly X 2 for residents receiving an antipsychotic to ensure an AIMS assessment is completed. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.