Failure to Follow Psychotropic Medication Policies and Informed Consent Requirements
Penalty
Summary
The facility failed to follow its own policy and federal regulations regarding the use of psychotropic medications for two residents. For one resident, an order for Ativan (lorazepam) 0.5 mg every six hours as needed for anxiety did not include a required 14-day end date. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that PRN psychotropic medications must have a 14-day limit, and the absence of an end date was acknowledged as a risk for unnecessary medication use. The facility's policy also specified this 14-day limitation for PRN psychotropic orders. For another resident, the facility did not obtain a signed informed consent for the use of Olanzapine (an antipsychotic) and Lorazepam. The resident was cognitively intact and had the capacity to make medical decisions, as documented in the medical record. The resident reported refusing the medication and stated that no consent had been signed. Review of the resident's records confirmed that the informed consent forms for these medications were not signed by the resident. The DON and LVN both stated the importance of informed consent, and the facility's policy required written informed consent before initiating psychotropic medications. Additionally, the resident prescribed Olanzapine did not have a documented diagnosis supporting the use of this medication in the admission record, as confirmed by the DON. The facility's policy required that psychotropic medications be prescribed only after a personal examination and with a specific diagnosis documented. The lack of a supporting diagnosis and missing informed consent for psychotropic medication use were direct violations of both facility policy and federal requirements.
Plan Of Correction
F758: Free from Unnecessary Psychotropic Meds/ PRN Use CORRECTIVE ACTIONS Resident 197's Ativan was discontinued on 3/18/25 as ordered by MD. No reports of new onset of acute distress noted related to previously not having a 14-day stop date. On 3/21/25, the SSD validated that the informed consent for Resident's 5 the use of Olanzapine and Lorazepam has been obtained. The informed consent verification was done on 3/21/25. OTHER RESIDENTS AFFECTED IDENTIFICATION The DON/Designee audited all residents on 3/21/25 to 3/28/25 receiving Psychotropic medications if a valid informed consent has been verified. There are 72 residents receiving Psychotropic medications - all informed consents for residents on Psychotropics have been verified from 3/21/25 to 3/28/25. All other residents with PRN psychotropics are noted with a 14-day stop date. MEASURE AND SYSTEMIC CHANGES The DON/Designee initiated education to licensed staff on 3/21/25 to ensure that any residents receiving psychotropic medications shall have an informed consent verified prior to initial administration and all PRN Psychotropics must have a 14-day stop date initially upon ordering. DON/DSD to monitor all PRN medication prescribed to ensure order is limited to 14 days. Bimonthly for 2 months, then monthly for 3 months, then quarterly thereafter. MONITORING PERFORMANCE The DON/SSD will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.