Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, bipolar disorder, and depression, was prescribed Olanzapine, an antipsychotic medication, without being informed of the associated benefits, risks, or alternatives. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 12 out of 15. Review of the medical record showed no documentation of consent or evidence that the resident or their responsible party had been provided with information regarding the use of Olanzapine. Interviews with facility staff revealed that the social worker was responsible for ensuring that residents or their representatives received and signed consent forms for psychotropic medications. However, the social worker was unable to provide any documentation of consent for this resident, and the DON confirmed that no such consent was present in the medical record. The resident was also unable to explain why they were receiving the antipsychotic medication. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives before initiating or increasing psychotropic medications, but this procedure was not followed in this case.