Failure to Obtain Updated Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain updated consent for the use of a psychotropic medication for one resident, as required by its own policy. The resident, who was admitted from an acute care hospital with diagnoses including psychosis, cannabis abuse with psychotic disorder, generalized anxiety disorder, mood affective disorder, and major depressive disorder, had intact cognitive function according to the most recent assessment. The care plan noted behavioral distress related to mental illness, and active physician orders included Depakote at specific dosages. Despite a previous consent form for Depakote being on file, it was signed several years prior and did not reflect the current dosage or regimen. Interviews with the Administrator and DON confirmed that facility policy requires new consent forms to be obtained whenever there is a change in medication dosage, and that the existing consent was outdated. The facility's policy specifically mandates obtaining consent for each psychotropic medication and updating it with any change in dose, which was not followed in this case.