Failure to Ensure Appropriate Diagnosis and AIMS Monitoring for Antipsychotic Use
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that a resident receiving a psychotropic medication had an appropriate psychiatric diagnosis and required monitoring. One resident was admitted with diagnoses including dementia, senile degeneration of the brain, major depressive disorder, a personal history of other mental and behavioral disorders, anxiety, and restlessness and agitation. Physician orders showed that this resident was prescribed quetiapine fumarate 50 mg twice daily for agitation, initially for a short period and then again for agitation and anxiety, and medication administration records documented that the resident received this antipsychotic medication over multiple months. Record review of the resident’s entire medical record revealed no order for an Abnormal Involuntary Movement Scale (AIMS) assessment and no documented AIMS assessments, despite the ongoing use of quetiapine. During interview, the Regional Clinical Nurse confirmed that the resident had an order for quetiapine for agitation and anxiety, did not have an appropriate diagnosis for the use of an antipsychotic medication, and that staff were expected to ensure residents were not administered antipsychotic medications unless they had a specific psychiatric diagnosis. The Regional Clinical Nurse also confirmed that staff did not complete an AIMS assessment on this resident and that staff were expected to complete an AIMS assessment prior to starting an antipsychotic medication and at least every three months thereafter.
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