Failure to Monitor Psychotropic Medication Side Effects and Complete AIMS Assessments
Penalty
Summary
Surveyors identified a deficiency in the facility’s monitoring of psychotropic medications for multiple residents. One resident with a diagnosis of depression was admitted on an unspecified date and had a physician’s order for citalopram hydrobromide 20 mg for depression. Medication administration records showed the antidepressant was administered consistently over several months. However, review of the resident’s entire medical record revealed no documentation that staff assessed for side effects of the antidepressant. In an interview, an LPN confirmed the resident had an order for citalopram, that staff were not monitoring for antidepressant side effects, and that such monitoring should have been documented on the Treatment Administration Record. The Regional Clinical Nurse also confirmed that staff were expected to monitor for antidepressant side effects. Surveyors also found that two residents receiving antipsychotic medications were not assessed using the Abnormal Involuntary Movement Scale (AIMS) despite pharmacy recommendations. One resident with schizophrenia had an order for thioridazine 10 mg twice daily, and pharmacy recommendations on three separate dates stated that the antipsychotic could cause tardive dyskinesia and other movement disorders and recommended a movement test within 30 days and then every six months. Another resident with unspecified dementia with behavioral disturbance had orders for mirtazapine for agitation and risperidone for psychosis, and pharmacy recommendations similarly advised a movement test within 30 days and then every six months. For both residents, record review showed no AIMS orders and no documented AIMS tests. In an interview, the DON confirmed there were pharmacy recommendations for movement tests for both residents and that an AIMS test should have been done initially upon admission and that the recommendations should have been followed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.