Failure to Complete Required AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
A deficiency was identified when the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments for a resident prescribed antipsychotic medication. The resident had multiple diagnoses, including psychosis, dementia with psychotic disturbance, and hallucinations, and was receiving olanzapine as ordered by a physician. The clinical record review revealed that the last documented AIMS assessment was completed nearly a year prior, despite ongoing antipsychotic therapy. The resident's care plan specifically noted the risk for adverse consequences related to antipsychotic medications and directed that AIMS testing be conducted according to guidelines. During an interview, a Clinical Support Nurse confirmed that there was no documented AIMS assessment available and acknowledged that one should have been performed. The facility's policy required AIMS assessments to be completed after admission, after antipsychotic medications are prescribed, with dosage changes, and to be repeated every six months. The lack of a current AIMS assessment for the resident on antipsychotic medication constituted a failure to follow both the care plan and facility policy.