Failure to Complete Baseline AIM Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct or document an initial or baseline abnormal involuntary movement (AIM) assessment for a resident who was prescribed an antipsychotic medication. The resident, who had diagnoses including dementia with psychotic disturbance and cognitive and communication deficits, was readmitted to the facility and received both antidepressant and antipsychotic medications on a routine basis. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms such as tardive dyskinesia, tremors, gait issues, and involuntary movements, there was no evidence in the electronic health record of a completed AIM assessment at admission or readmission. Observations showed the resident exhibiting various movements, such as moving legs and feet, and manipulating their gown, but staff were unable to locate any AIM assessment documentation. Interviews with both an LPN and the Director of Nursing confirmed that an AIM scale assessment should have been completed and documented for residents on antipsychotic medications, but this was not done for this resident. Both staff members acknowledged that this failure did not meet facility expectations.