Failure to Obtain Valid Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain proper informed consent for a psychotropic medication for one resident. The resident, who had diagnoses of dementia and anxiety disorder, was assessed as having severe cognitive impairment and was documented as lacking the capacity to understand and make decisions. Despite this, when the resident's Seroquel dosage was increased from 50 mg to 100 mg twice daily, the informed consent for the new dosage was obtained directly from the resident, rather than from a resident representative or responsible party as required by facility policy and the resident's documented incapacity. Interviews with facility staff, including the nurse practitioner and assistant director of nursing, confirmed that informed consent should be obtained from the resident or their representative prior to administering psychotropic medications, especially when there is a dosage change. The facility's policy also required that the prescribing clinician obtain informed consent from the appropriate party before administration. The failure to follow these procedures resulted in the administration of a higher dose of Seroquel without valid informed consent, as the resident was not capable of providing it.