Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document the required informed consent from the guardians of two residents prior to administering psychotropic medications. In the first case, a resident with major depressive disorder and early-onset Alzheimer's disease, who was severely cognitively impaired as indicated by a BIMS score of 0, was prescribed Lorazepam (Ativan) for anxiety. The resident's family member, who is also the guardian, reported not being informed about the new medication order. Review of the medical record confirmed that although a request for consent was initiated, a signed consent was not obtained or available for review at the time of the survey. In the second case, another resident with dementia, who was not interviewable, was prescribed Zyprexa (an antipsychotic). Similarly, there was no signed consent obtained or available for review by the time of the survey. Both instances demonstrate that the facility did not ensure that the residents' guardians were fully informed and had provided documented consent prior to the administration of psychotropic medications.
Plan Of Correction
F552 – Right to be Informed/Make Treatment Decisions Element #1: For Residents #33 and #41, physician orders for psychotropic medications were reviewed, and informed consent forms were obtained as necessary. The guardians were notified and documentation updated in the medical record. Element #2: A comprehensive audit of all residents on psychotropic medications was completed by the Director of Nursing to verify that current signed informed consents are present in the medical record. Any missing documentation will be obtained and filed. Element #3: The Administrator and Director of Nursing implemented a new Psychotropic Medication Informed Consent to ensure residents/responsible parties are made aware of the medication, benefits, potential adverse reactions, and alternate interventions. Licensed Nurses were re-educated on this document and the requirement for a signed consent prior to the distribution of the medication. Element #4: The Director of Nursing or designee will audit all new psychotropic medication orders weekly for 12 weeks to verify compliance with informed consent requirements. Results of the audits will be submitted to the QAPI.