Failure to Monitor and Report Tardive Dyskinesia in Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medications was free from chemical restraints and received appropriate monitoring for side effects, specifically tardive dyskinesia. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cognitive impairment, was observed repeatedly smacking her lips, a symptom consistent with tardive dyskinesia, during multiple observations over several days. Despite these visible symptoms, there was no documentation in the resident's medical record, medication administration records, or progress notes indicating that these symptoms were recognized, monitored, or reported to the physician. Staff interviews revealed that nursing staff, including RNs and LPNs, were aware that the resident had been exhibiting signs of tardive dyskinesia since admission. However, this information was not documented in the resident's records, nor was it communicated to the attending physician or psychiatrist. The facility's policy required monitoring and documentation of side effects, including tardive dyskinesia, and completion of the Abnormal Involuntary Movement Scale (AIMS) assessment quarterly. The most recent AIMS assessment did not reflect the observed symptoms, and there was no evidence of ongoing monitoring or timely notification to medical providers regarding the resident's condition. Additionally, the social services director acknowledged awareness of the resident's tardive dyskinesia but did not communicate this to the physician or psychiatrist. The resident's care plan included interventions for monitoring side effects, but these were not implemented as required. The lack of documentation and communication resulted in a failure to ensure the resident was appropriately monitored for adverse effects of antipsychotic medications, as required by facility policy and professional standards.