Failure to Obtain and Document Medication Consent for Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in advance about the medications they were receiving, including the reasons, risks, and benefits associated with those medications. For one resident with a physician's order for trazodone to address sleep issues related to systolic heart failure, staff did not document obtaining consent for the medication. The Director of Nursing (DON) confirmed that the required psychotropic medication consent form was not completed prior to the resident starting the medication, as expected by facility policy. Similarly, another resident had physician's orders for hydroxyzine for anxiety and trazodone for insomnia, but staff did not document consent for either medication. The DON confirmed that staff failed to obtain the necessary consent forms for both medications. The DON also stated that nurses are expected to obtain verbal consent before administering the first dose and then follow up with a written consent signed by the resident's power of attorney, but this process was not followed in these cases.