Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and their own responsible party, was administered aripiprazole, an antipsychotic medication, without being informed of the reason for its use or the associated risks and benefits. The resident's medical record, including the Medication Administration Record and electronic documentation, did not contain any evidence that this information was provided prior to the administration of the medication. The resident had diagnoses including dementia and cerebral infarction, and had been receiving aripiprazole since admission. During the survey, the Nursing Home Administrator was unable to provide documentation that the resident had been informed about the medication's purpose or its risks and benefits. Although the administrator indicated that the physician would speak to the resident about the medication, no documentation of such a discussion was available by the time the survey concluded. As a result, the facility failed to meet the requirement to inform the resident in advance about their treatment, including the risks and benefits of the prescribed psychotropic medication.
Plan Of Correction
1. Residents #350 still currently resides in the facility. She was educated on and consented to the use of Abilify on 3/28/2025. 2. Like residents are identified as those who are ordered antipsychotic medications. They have the potential to be affected by this deficient practice. A sweep was completed by 4/23/2025 to ensure all like residents have the appropriate education and consent documented and their plan of care updated as needed. 3. Policy on the use of antipsychotic medications was reviewed and deemed appropriate. Licensed nurses and social work staff were in-serviced between by 4/25/2025 on appropriate procedures. 4. The QAPI committee has directed the DON/designee to perform random weekly audits on residents who are ordered antipsychotic medications to ensure the proper procedure is followed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.