Failure to Obtain Psychotropic Medication Consent Prior to Administration
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia, depression, and anxiety, was unable to clearly verbalize needs and frequently refused care. Despite being prescribed multiple psychotropic medications such as Lexapro, Risperidone, Trazodone, and Ativan, there was no documentation of signed or verbally discussed consents for these medications prior to their administration. Record review confirmed the absence of psychotropic medication consents, and staff interviews verified that no consents were on file before a specified date. The resident's care plan included interventions to provide education on the risks and benefits of these medications, but there was no evidence that this was carried out as required by facility policy. This resulted in the resident and/or their representative not being fully informed about the medications being administered.