Failure to Notify Physician and Representative of Significant AIMS Score Increase
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative of a significant change in the resident’s Abnormal Involuntary Movements Scale (AIMS) score. Facility policy dated 02-2021 stated that an AIMS score of 2 or higher is evidence of Tardive Dyskinesia (TD), and that if a resident’s score suggests TD, the results should be discussed with the physician, resident, and family, and the need for continued antipsychotic therapy should be considered. Record review showed that the resident, who had anxiety disorder, bipolar disorder, and schizophrenia, was rarely able to make self understood and required total assistance with activities of daily living. The resident was receiving Seroquel 25 mg daily, and additional doses of Seroquel 100 mg at bedtime and 25 mg at noon were later added. An AIMS assessment conducted on 09-17-2025 showed a score of 0, but a subsequent AIMS assessment on 11-04-2025 showed an increased score of 4. Despite this documented increase, which met the facility’s policy threshold for possible TD and required discussion with the physician and family, there was no evidence that the physician or the resident’s representative were informed of the change in the AIMS score. In an interview on 01-08-2026, the DON confirmed that the resident had an increase in the AIMS score and that the facility did not update the resident’s representative or the physician of this increase and acknowledged that they should have done so.
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