Failure to Complete Required Assessments and Lab Monitoring
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments due to psychotropic medication use. A physician's order specified that AIMS assessments should be completed quarterly in March, June, September, and December. However, records showed that the last AIMS assessment was completed in August 2024, with no evidence of assessments being performed on the subsequent required dates. Both the resident's Nurse Practitioner and the Director of Nursing Services confirmed that the assessments had not been completed as ordered. For another resident with diabetes mellitus and hyperglycemia, the care plan identified risks related to diabetes and insulin administration. The resident was prescribed daily Semglee (insulin glargine-yfgn), and a provider's note indicated that a hemoglobin A1C test should be repeated in three months following a previous test. However, there was no evidence that the follow-up hemoglobin A1C was completed as ordered. The Director of Nursing Services acknowledged that the last A1C test was in November 2024 and could not provide documentation of a repeat test until after the issue was identified by the surveyor.