Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for the use of psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents. Record reviews and staff interviews confirmed that for five residents with various diagnoses such as bipolar disorder, depression, dementia, schizophrenia, and schizoaffective disorder, there was no documented evidence of informed consent for the administration of these medications. The medications in question included Haldol, Seroquel, Escitalopram, Zyprexa, Clonazepam, Divalproex, Clozapine, Mirtazapine, Lorazepam, Sertraline, Depakote, and Geodon. Interviews with the Director of Nursing and the Regional Director of Clinical confirmed the absence of required consents in the residents' medical records. Some of the residents were noted to be cognitively intact based on their BIMS scores, indicating they were capable of providing consent. Despite this, the facility did not obtain or document consent for the use of psychotropic medications, as required, for any of the five residents reviewed.