Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided informed consent prior to the administration of a psychotropic medication, specifically lorazepam. The resident, who had diagnoses including end stage renal disease, dependence on hemodialysis, and monoplegia of the upper limb, was assessed as having the capacity to understand and make decisions. Documentation showed that the resident was able to communicate effectively and was self-responsible for medical decisions. Despite this, there was no evidence that informed consent was obtained or documented before lorazepam was administered. Review of the resident's care plan indicated that education regarding the risks, benefits, and side effects of lorazepam was required, and the facility's policy mandated written informed consent for psychotropic medications, with renewal every six months. Interviews with facility staff, including the MDS Coordinator, LVN, ADON, and DON, confirmed that informed consent was not obtained or documented for lorazepam, even though the process was followed for another psychotropic medication prescribed at the same time. The resident also stated that the risks and benefits of lorazepam were never explained and did not recall signing any consent form. Facility policy required the healthcare practitioner to obtain informed consent and the licensed nurse to verify and document this before administering any psychoactive medication. The absence of informed consent for lorazepam was acknowledged by multiple staff members, who stated that this was not in accordance with facility policy and procedures. The lack of documentation and resident education prior to administration of lorazepam constituted a failure to protect the resident's right to make informed medical decisions regarding psychotropic medication use.