Failure to Inform Resident Representative of Psychotropic Medication Initiation
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of the initiation of a psychotropic medication, including the associated risks, benefits, and alternative treatment options. The resident in question was admitted with diagnoses of dementia and encephalopathy and was assessed as being severely cognitively impaired, with a BIMS score of 05. Despite having a designated power of attorney as a resident representative, the clinical record showed that consent for the antipsychotic medication Seroquel was documented as verbal consent from the resident, with no evidence that the representative was informed or involved in the decision-making process. Further review of the resident's records revealed no documentation that the responsible party was notified about the new medication, nor that the risks, benefits, or alternative treatments were discussed. The resident received Seroquel for an extended period before the representative inquired about the medication and expressed opposition to its use. The facility was unable to provide documentation of the pre-hospital medication list supplied by the representative, and the Nursing Home Administrator confirmed the absence of documentation regarding notification or informed consent from the resident's representative.