Failure to Monitor for Tardive Dyskinesia in Resident Receiving Antipsychotics
Penalty
Summary
The facility failed to ensure adequate monitoring for tardive dyskinesia (TD) in a resident who was prescribed antipsychotic medication. The resident, who had impaired cognition and multiple medical diagnoses including dementia, encephalopathy, and behavioral disturbances, was receiving risperidone for agitation and delirium. The care plan directed staff to follow mental health provider recommendations but did not include baseline monitoring for side effects of antipsychotic medication. Review of the resident's medical record showed no evidence that an Abnormal Involuntary Movement Scale (AIMS) evaluation had been completed prior to the surveyors' request. The Medication Administration Record confirmed ongoing administration of risperidone, but documentation of required AIMS testing was absent. The DON acknowledged that AIMS evaluations are important for assessing TD and should be completed at admission and every six months for residents on antipsychotics. However, the AIMS evaluation for this resident was only completed after surveyors requested documentation, indicating a lapse in timely monitoring as required by facility policy.