Failure to Obtain Timely and Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain written informed consent for the administration of a psychotropic medication to one resident prior to starting the medication. The facility's policy required that psychotropic medications be administered only after obtaining informed consent from the resident or their responsible party. The resident, who was admitted with diagnoses including bipolar disorder, anemia, osteoarthritis, diabetes mellitus, hypertension, and atrial fibrillation, was assessed as having moderate cognitive impairment but was still able to make their own decisions, as their Health Care Proxy was not activated. Despite this, the resident was administered quetiapine fumerate, an antipsychotic medication, starting in early February, without any documentation of written informed consent in the medical record. Written consent was not obtained until over a month after the medication had been initiated. Furthermore, the consent form that was eventually signed did not match the resident's current medication order, as the dosage range on the consent form was lower than the actual prescribed dose. The DON confirmed that no documentation of informed consent prior to administration could be found and acknowledged that consent should have been obtained before starting the medication.