Failure to Complete Physician-Ordered Assessments and Notify Physician of Held Insulin Doses
Penalty
Summary
A deficiency occurred when a physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was not completed as required for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired and had diagnoses including Wernicke's Encephalopathy, anxiety disorder, amnestic disorder, and drug-induced subacute dyskinesia, exhibited abnormal movements such as hand tremors, constant leg movement, and restlessness. Despite a physician's order to complete an AIMS assessment and provide updates on mood, behaviors, and PRN Lorazepam use, there was no documentation that these assessments or communications were completed after the last recorded AIMS assessment. The DON confirmed that the required assessment and updates were not performed or communicated to the physician as ordered. Another deficiency was identified regarding the management of insulin for a resident with diabetes. The resident's insulin doses were repeatedly held due to low blood sugar readings or lack of appetite, but there was no physician order specifying parameters for when to hold insulin until later in the month. Documentation showed that the physician was not notified each time insulin was held, and staff interviews confirmed that notifications were not consistently made. The medical director stated that immediate notification was expected when insulin was held for hypoglycemia, but this did not occur. The facility lacked a policy specifically addressing physician notification for held or refused medications, and documentation of physician notification for the held insulin doses was not provided. Policy reviews revealed that while there were general protocols for physician visits, medication orders, diabetes management, and notification of resident changes, there were gaps in policies related to following physician orders unrelated to medications and specific guidance on physician notification for held or refused medications. The absence of clear documentation and communication with the physician regarding both the AIMS assessment and insulin management led to the deficiencies identified during the survey.