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F0757
D

Failure to Complete Required AIMS Assessment for Antipsychotic Medication

Raleigh, North Carolina Survey Completed on 08-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed an antipsychotic medication, quetiapine fumarate, for dementia with psychosis. The resident, who had severe cognitive impairment and a diagnosis of vascular dementia without behavioral disturbances, was restarted on quetiapine after a period of discontinuation. The care plan required an AIMS assessment every six months, and the facility's records indicated that the assessment was not completed when the medication was re-initiated, nor had it been completed up to the time of the survey. The Consultant Pharmacist confirmed that an AIMS assessment is required at the start of antipsychotic therapy and every six months thereafter, and noted that she had notified the facility's DON and Administrator when she identified the missing assessment during her monthly review. The DON and Administrator both acknowledged that the transition to a new Mental Health and Antipsychotic Review process may have caused the AIMS assessment to be missed for this resident, as the new process did not trigger the required assessment when the antipsychotic was restarted.

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