Failure to Accurately Complete AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric diagnoses, including schizophrenia and dementia, did not receive an accurate Abnormal Involuntary Movement Scale (AIMS) assessment. The resident was prescribed Risperidone, an antipsychotic medication, and had a care plan in place to monitor for psychotropic drug-related complications, including movement disorders. Despite this, the AIMS assessment completed by a registered nurse documented 'none' for involuntary movements in the resident's upper extremities, even though the resident reported and was observed to have irregular, bothersome shaking and jerking of the right arm, particularly during eating. The nurse later admitted to being in a hurry and not marking the correct level of involuntary movement on the assessment. Further interviews with the Director of Nursing confirmed that the resident did have moderate involuntary movement in the right arm and that the AIMS assessment was completed incorrectly. The administrator also stated that the facility did not have a policy regarding AIMS assessments. These actions and omissions resulted in the resident not receiving an accurate assessment as required.