Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document consent for psychotropic medications for two residents. For one resident with major depressive disorder and agitation, physician orders included Seroquel and Sertraline, but there was no documented evidence that consent was obtained prior to starting these medications. For another resident with adult failure to thrive and depression, physician orders included Duloxetine and Olanzapine, also without documented consent prior to initiation. The interim DON confirmed that consents for these medications were not present in the medical records and acknowledged that such consents are required to ensure residents or their representatives are informed about the medications' effects and possible side effects. Facility policy requires that, before starting or increasing psychotropic medications, residents, families, or representatives must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotics. Despite this policy, the required documentation of informed consent was missing for both residents at the time of the survey, as confirmed by record review and staff interview.