Failure to Obtain Consent Before Administering New Medication
Penalty
Summary
Facility staff failed to obtain consent from a resident's representative prior to administering a new medication. The resident, who had a diagnosis including dementia and was assessed to have severe cognitive impairment with a BIMS score of 4 out of 15, was seen by a psychiatric practitioner who ordered Depakote for behavioral disturbances. Documentation indicated that the practitioner was unable to reach the resident's representative to discuss the treatment plan, and there was no evidence in the medical record that the representative was notified before the medication was given. The resident's representative later confirmed that medications were administered without a meeting to discuss the behavior or care plan. The Assistant Director of Nursing also confirmed that there was no evidence of notification prior to administration.