Failure to Obtain and Document Informed Consent for Psychoactive Medications and Bed Alarms
Penalty
Summary
The facility failed to follow its own policies and procedures regarding informed consent for psychoactive/psychotropic medication use and the use of bed alarms for multiple residents. In several cases, consent forms for psychoactive medications such as escitalopram, amitriptyline, alprazolam, venlafaxine, bupropion, sertraline, Seroquel, lorazepam, and clonazepam were either missing required physician signatures, lacked verification by a licensed nurse, or were not signed by the resident or their responsible party. In some instances, documentation of informed consent was entirely absent, despite the medications being administered. The facility's policy required that the prescribing clinician obtain and document informed consent, and that a licensed nurse verify and sign the consent form prior to medication administration, but these steps were not consistently followed. The report details that for several residents, including those with varying levels of cognitive impairment as measured by the Brief Interview for Mental Status (BIMS), informed consent forms were incomplete or missing. For example, one resident with a BIMS of 12 had consent forms for two psychoactive medications that were not signed by a physician. Another resident with a BIMS of 3 had an incomplete consent for alprazolam, and a resident with a BIMS of 7 had no documentation of consent for lorazepam, despite receiving the medication on multiple occasions. In other cases, the responsible party's signature was present, but there was no verification by a nurse or physician, as required by policy. Additionally, the facility failed to obtain and document informed consent for the use of bed alarms for two residents. The consent forms for these interventions were incomplete, lacking signatures from a nurse or physician, and in one case, the responsible party's signature was not clearly documented. The facility's policy required that the physician provide education to the resident or responsible party about the risks, benefits, and alternatives of such interventions, and that informed consent be properly documented, but this was not done consistently.