Failure to Notify Physician of Change in Condition Following Increased AIMS Score
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, delusional disorders, and anxiety disorder. The resident was prescribed increasing doses of quetiapine, an antipsychotic medication, over several months. An initial Abnormal Involuntary Movement Scale (AIMS) assessment showed no involuntary movements, but a follow-up assessment revealed a notable increase in symptoms, with the AIMS score rising from 0 to 4. Despite this documented change, there was no evidence in the clinical record that the physician had been notified of the new onset of tardive dyskinesia symptoms. Interviews with the consulting pharmacist and the director of nursing confirmed that changes in AIMS scores should be communicated to the provider, and that nurses are expected to document such notifications in the clinical record. Both the pharmacist and DON emphasized the importance of notifying the physician to ensure resident safety and appropriate medication management. The facility was unable to provide a policy regarding this process, and the clinical record lacked documentation of physician notification following the resident's increased AIMS score.