Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain consent for the administration of psychotropic medications for two of five sampled residents reviewed for unnecessary medications. Facility policy requires that residents, families, and/or representatives be involved in the medication management process, and that psychotropic medications are not administered unless clinically indicated and with proper documentation. However, review of medical records and interviews revealed that consent was not obtained for the use of antipsychotic and antidepressant medications for two residents. One resident with severe cognitive impairment and diagnoses including psychosis and dementia was prescribed and administered Seroquel and Zoloft. Medical records showed ongoing use of these medications, but there was no documentation of consent from the resident's family or representative. In a telephone interview, the resident's family member stated they were unaware of the medications being administered. Another resident, who was cognitively intact and diagnosed with bipolar disorder, depression, and anxiety, received multiple psychotropic medications including Ativan, Risperidone, and Trazodone. Medical record review confirmed frequent administration of these medications, but again, no consent forms were found. Interviews with facility staff, including the Social Service Director and DON, confirmed that consents for psychotropic medications had not been obtained for these residents at the time of review.