Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of Ativan (lorazepam), a psychoactive medication, for a resident with severe cognitive impairment. The resident was admitted with diagnoses including dementia, anxiety disorder, and psychosis, and was determined by a physician to lack the capacity to understand and make decisions. The resident's Minimum Data Set assessment confirmed severe cognitive impairment and indicated the use of antianxiety medication. A physician order was present for Ativan to be administered as needed for inconsolable yelling. However, upon review of the resident's medical record, the Social Services Director was unable to locate a signed informed consent for the use of Ativan. Further investigation confirmed that the resident's responsible party had not provided documented consent for the medication. Interviews with facility staff, including the Director of Nursing, confirmed that facility policy requires informed consent to be obtained and documented prior to administering psychoactive medications, especially when the resident is unable to provide consent. The policy specifies that consent must be obtained from the resident's representative if the resident is not capable. Despite this, there was no evidence that informed consent was obtained or documented for the use of Ativan in this case.
Plan Of Correction
Corrective Action: Resident 77's informed consent for use of Ativan was obtained and verified by a licensed nurse from RP1 on 4/16/25. Other Residents Affected Identification: All residents taking Psychotropic Medications are at risk for deficient practice. On 4/17/25, all residents on Psychotropic Medications were reviewed for completion of Informed Consents. No other residents were affected by the deficient practice. Measures and Systemic Changes: On 04/17/2025, the DON initiated in-service to Licensed Nurses and SSD to ensure that consents are obtained prior to giving psychotropic medication. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee 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. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee 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.