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F0605
D

Failure to Complete Required AIMS Assessments Prior to Psychotropic Medication Administration

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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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

The facility failed to ensure that two residents were free from chemical restraints by not performing required Abnormal Involuntary Movement Scale (AIMS) assessments prior to administering psychotropic medications. According to the facility's policy, a baseline AIMS assessment should be completed before starting antipsychotic medications, with reassessments every six months. For one resident with Alzheimer's disease and dementia, the surveyor found no evidence of an AIMS assessment in the electronic medical record despite the resident receiving Quetiapine Fumarate, an antipsychotic medication. The facility was unable to provide the requested AIMS assessment for this resident during the survey. Another resident, who had multiple diagnoses including Alzheimer's disease, dementia, and Parkinson's disease, was prescribed Memantine and Mirtazapine, both psychotropic medications. The surveyor noted that while an AIMS assessment was eventually provided, it was not completed prior to the initiation of these medications. The lack of timely AIMS assessments for both residents was confirmed through record review and interviews with facility staff, indicating non-compliance with the facility's own policy regarding the monitoring of residents on psychotropic medications.

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