Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were fully informed and provided with written informed consent prior to the administration of psychoactive medications. For two sampled residents, the required documentation of informed consent was not found for several prescribed psychotropic medications, including lorazepam, mirtazapine, escitalopram, and gabapentin. This omission was identified through interviews and record reviews, where staff confirmed the absence of signed consents in the residents' medical records. One resident, who had a history of depression, insomnia, and atrial fibrillation, was admitted with moderate cognitive impairment and was prescribed multiple psychoactive medications for anxiety, depression, and insomnia. Despite the facility's policy requiring written informed consent for such medications, no documentation of consent was present for any of the prescribed drugs. Staff interviews confirmed that the process of obtaining and documenting informed consent, including discussion of risks and benefits, had not been completed as required. A second resident, also with moderate cognitive impairment and diagnoses of anxiety disorder, depression, and diabetes mellitus, was prescribed escitalopram for depression and anxiety. Again, review of the medical record and interviews with nursing staff revealed that no written informed consent was obtained or documented for the use of this psychotropic medication. The facility's policy, which mandates informed consent and regular renewal every six months, was not followed in these cases, resulting in a violation of the residents' rights to make informed decisions regarding their care.