Failure to Complete Ordered AIMS Monitoring for Antipsychotic Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete ordered monitoring for side effects of psychotropic medication for one resident. The resident was admitted with multiple psychiatric diagnoses, including dementia with psychotic disturbance, psychotic disorder with delusions, and schizophrenia, and an AIMS assessment completed at admission showed a score of 3, indicating mild abnormal movements associated with antipsychotic use. The following day, a physician ordered quetiapine twice daily. During a subsequent consultant pharmacist medication regimen review, the pharmacist noted the baseline AIMS score of 3 and recommended obtaining an order to repeat the AIMS assessment due to the ongoing antipsychotic therapy. The primary care provider agreed with this recommendation and documented an order to repeat the AIMS assessment. However, review of the clinical record months later showed no evidence that a repeat AIMS assessment had been completed, and the DON confirmed that instead of performing the ordered repeat AIMS, another psychiatric assessment was done while the DON was on vacation. These findings were confirmed through record review and interviews and were discussed with facility leadership during the exit conference.
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