Failure to Refer for Neurological Exams After Abnormal AIMS Scores
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications were adequately monitored for abnormal involuntary movements, as required by their own protocols. Specifically, two residents with diagnoses including dementia, schizophrenia, anxiety, and bipolar disorder were identified as having Abnormal Involuntary Movement Scale (AIMS) assessment scores that necessitated referral for a complete neurological exam. For one resident, an AIMS assessment documented a score of 3 in one body area, which required a neurological referral, but no such referral or exam was found in the medical record. For the other resident, an AIMS score of 5 was recorded, also requiring a referral for a complete neurological exam, but there was no evidence that this referral or exam was completed. Interviews with facility staff, including the President of Success-D, the DON, and an RN, confirmed that the expected process following such AIMS scores was not followed. Staff acknowledged that a referral should have been made and that the provider should have been notified, but this did not occur. The deficiency was identified through record review and staff interviews, with no additional information provided by the facility to explain the lack of follow-through on required neurological assessments.