Failure to Complete Required AIMS Assessments and Daily Weights
Penalty
Summary
The facility failed to ensure that Abnormal Involuntary Movement Scale (AIMS) assessments were completed as required and that daily weights were consistently obtained for two residents. For one resident with diagnoses including bipolar disorder, anxiety disorder, delusional disorder, and dementia, the care plan identified a risk for adverse side effects from antipsychotic and antidepressant medications. Although there were physician orders for psychotropic medications, the AIMS assessment was not completed within the required timeframe, with the last valid assessment dated several months prior and a subsequent assessment marked as completed in error. Interviews with nursing staff revealed inconsistent understanding of the required frequency for AIMS assessments, ranging from every three to six months, and confirmed that nursing staff were responsible for their completion. For another resident with diagnoses including diabetes mellitus, congestive heart failure, and anxiety disorder, the care plan required daily weights to monitor for significant weight changes due to heart failure. Despite a physician's order for daily weights and instructions to notify the nurse practitioner of significant weight gain, documentation showed multiple days across several months where daily weights were not recorded. Interviews with the DON, LPN, and CNA confirmed that the process for obtaining and documenting weights involved both nursing and CNA staff, but weights were not consistently documented as required by the care plan and physician's order.