Failure to Assess for Antipsychotic Side Effects
Penalty
Summary
The facility failed to perform an assessment for side effects related to ongoing antipsychotic medication use for a resident diagnosed with Pick's Disease, unspecified dementia with behavioral disturbance, and anxiety disorder. The resident was unable to complete cognitive assessments and exhibited physical and verbal behaviors directed toward others, as well as rejection of care. The care plan included monitoring for side effects and changes in cognitive function, and the resident had an active order for Seroquel, an antipsychotic medication. However, the electronic medical record did not contain evidence of any assessment, such as the Abnormal Involuntary Movement Scale (AIMS), to identify abnormal involuntary movements associated with antipsychotic use. Interviews with nursing staff revealed inconsistent understanding of the facility's policy regarding the frequency of AIMS assessments, with some staff stating it should be done quarterly, others at admission and quarterly, and another stating every six months. Facility policy required AIMS assessments on admission, every six months, and as needed for residents on antipsychotic medications. Despite these requirements, there was no documentation that the required AIMS assessments were completed for the resident receiving Seroquel.