Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed in advance about the risks and benefits of a psychoactive medication, specifically Remeron (mirtazapine), which was prescribed for depression manifested by poor appetite. The resident had a history of chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder, and was assessed as being able to make needs known but unable to make medical decisions. Despite this, there was no documented informed consent for the use of Remeron, as confirmed during interviews and record reviews with facility staff. The MDS Nurse and a Registered Nurse both acknowledged that the informed consent process was missed, with the RN stating she failed to complete the consent when the medication order was received. The Director of Nursing confirmed that it is the responsibility of licensed nurses to obtain informed consent prior to administering such medications, in accordance with facility policy. The facility's policy requires verification of informed consent with each order, but this was not followed in this instance.