Failure to Identify and Report Missing AIMS Test During Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for a resident with multiple diagnoses, including congestive heart failure, diabetes mellitus, and gastroesophageal reflux. The resident had intact cognition and was receiving insulin, a diuretic, and an antidepressant, as documented in the Minimum Data Set (MDS) and Care Area Assessment (CAA). The resident was also prescribed Reglan (Metoclopramide HCl), an antiemetic, to be taken before meals for nausea. Despite this, the Monthly Medication Reviews (MMRs) for August and September did not include documentation or recommendations for an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary to monitor for adverse effects associated with Reglan. Interviews with nursing staff revealed that AIMS testing was not completed for the resident, and the facility was unable to provide evidence of an AIMS test when requested. The administrative nurse acknowledged that the CP should have identified the lack of an AIMS test and that the issue was brought to the attention of both the CP and the corporate office. The facility's policy required the pharmacy to have access to complete medical records and the ability to document in the resident's record, but the deficiency occurred due to the CP's failure to identify and report the missing AIMS test during the monthly drug regimen review.