Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to document that residents and/or their representatives were fully informed of the risks and benefits of psychotropic medications for five residents who were reviewed for unnecessary medications. Record reviews for these residents showed active physician orders for various psychotropic medications, including Citalopram, Lorazepam, Lexapro, Mirtazapine, and Sertraline, prescribed for conditions such as depression, anxiety, insomnia, and major depressive disorder. However, there was no documentation in the medical records indicating that the residents or their representatives had been informed about the potential risks and benefits associated with these medications prior to starting treatment. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the absence of documentation regarding informed consent for the use of psychotropic medications for the affected residents. The lack of documentation was consistent across all five residents reviewed, as evidenced by the findings from both record and policy reviews.