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F0552
E

Failure to Obtain Informed Consent for Psychoactive Medication

La Verne, California Survey Completed on 04-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent from the responsible party prior to administering a psychoactive medication, Seroquel, to a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson's disease, dementia, and a history of falls, was unable to make medical decisions. Despite this, Seroquel was ordered and administered for psychosis manifested by visual hallucinations and aggression, without documented evidence that the responsible party was informed of the risks and benefits or that consent was obtained. Record reviews confirmed that the medication was given on multiple occasions, and both the LVN and DON acknowledged that informed consent was required for psychotropic medications, as per facility policy. The facility's policy specified that the physician must inform the resident or representative and obtain consent before use of such medications. The lack of documented consent meant the responsible party was not given the opportunity to make an informed decision regarding the resident's treatment.

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