Failure to Obtain and Document Accurate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained and documented prior to administering psychotropic medications for three residents. In one case, a resident with severe cognitive impairment and delirium was prescribed aripiprazole, but the informed consent form incorrectly identified the medication as an antidepressant rather than an antipsychotic. As a result, the resident or their representative was educated about the risks and benefits of antidepressants instead of antipsychotics, and staff confirmed that the resident could not have made an informed decision based on inaccurate information. For another resident with severe cognitive impairment, there was no documented consent for an increased dose of quetiapine or for the administration of lorazepam, both psychotropic medications. Staff acknowledged that consents should have been obtained with these medication changes but were not. In a third case, a resident with dementia was found to have provided consent for psychotropic medications despite being unable to do so, and the resident's son, who was not the active power of attorney, was present at the time. Additionally, there was no consent found for trazodone, another psychotropic medication. These findings indicate that the facility did not consistently ensure that informed consent was obtained from the appropriate party and that the consent process accurately reflected the medications and their associated risks.