Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a complete and accurate medical record was maintained for a resident who was prescribed psychotropic medications. Specifically, there was no documentation in the resident's medical record indicating that informed consent was obtained for the administration of Temazepam and Trazodone, both psychotropic medications. The resident's face sheet showed admission with diagnoses including heart failure and unspecified atrial fibrillation. Physician orders for Temazepam and Trazodone were present, and the Medication Administration Record confirmed that these medications were administered on multiple occasions. Interviews with the DON and an RN revealed that the physician was responsible for discussing the treatment and obtaining written consent, and that nursing staff should verify the presence of a signed consent form before administering psychotropic medications. Review of facility policy confirmed that written informed consent must be documented and filed in the resident's health record prior to initiating psychotropic drug therapy. Despite these requirements, no such documentation was found in the resident's record at the time of review.