Incomplete Documentation of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents by not verifying that the physician obtained informed consent prior to initiating psychotropic medications. For one resident with anxiety disorder and moderate cognitive impairment, the Verification of Informed Consent for Buspirone did not indicate the prescribing physician's name or confirm that the prescriber obtained informed consent from the resident. The form was signed by the resident but lacked documentation of the prescriber's involvement in the consent process. For another resident with major depression, dementia, and severe cognitive impairment, the Verification of Informed Consent for Mirtazapine, Quetiapine, and Buspirone did not indicate the prescriber and, although signed by the next of kin, did not confirm that the prescriber obtained informed consent from the responsible party. Both the registered nurse supervisor and the director of nursing confirmed that the consent forms were incomplete and did not meet facility policy requirements, which specify that documentation must confirm the physician obtained informed consent and that no blank spaces are left on forms.