Failure to Monitor for Adverse Effects of Antipsychotic Medication
Penalty
Summary
The facility failed to monitor and document adverse consequences of an antipsychotic medication, Clozapine, for one resident. According to facility policy, residents on psychotropic drugs must be monitored for effectiveness and side effects, with the Abnormal Involuntary Movement Scale (AIMS) assessment required at initiation of therapy and at least every six months thereafter. The resident in question, who was severely cognitively impaired and diagnosed with psychosis and delusional disorder, had been receiving Clozapine as prescribed since November of the previous year. The last documented AIMS assessment for this resident was completed in July, with no subsequent AIMS performed for the following ten months, despite ongoing administration of Clozapine. A pharmacist's monthly medication review in December specifically recommended that an AIMS assessment be completed immediately and then every six months. However, there was no evidence in the medical record that this recommendation was acted upon, nor was there documentation of a current AIMS assessment after the initial one. Interviews with facility staff, including the Unit Manager, Staff Development Coordinator, and Director of Nursing, confirmed that the AIMS assessment was overdue and that there was no current system in place for tracking AIMS testing. Staff acknowledged that recommendations from the pharmacy were received and should have been addressed, but the required monitoring was not completed as per policy and professional standards.