Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain consent for an antipsychotic medication prior to its initiation for one resident. The resident, who had diagnoses including bipolar disorder, type 2 diabetes mellitus, and unsteadiness on feet, was admitted with intact cognition as evidenced by a perfect score on the BIMS assessment. Physician orders indicated the resident was to receive Haloperidol for bipolar disorder, and the Medication Administration Record confirmed the medication was administered on multiple occasions. Review of the electronic medical record revealed that no consent for the antipsychotic medication had been signed by the resident. Interviews with the Social Services Director and the Director of Nursing confirmed that the required consent was not present in the record and had not been completed, despite facility policy requiring education and consent for antipsychotic drug use.