Failure to Obtain Resident Consent for Vaccinations, Psychotropic Medications, and Safety Devices
Penalty
Summary
The facility failed to obtain proper consent from residents or their representatives prior to administering vaccinations, psychotropic medications, and safety devices. Specifically, several residents received Covid-19, flu, and pneumonia vaccines without documented consent, and in some cases, there was no supporting documentation for historical vaccinations. For example, residents received vaccinations for the 2024/2025 season without signed consent forms, and in one case, a resident's name was typed on a consent form without a signature. Staff interviews confirmed that signed consents were expected but not obtained, and that documentation from the Department of Health was missing for some historical immunizations. In addition, the facility did not obtain consent prior to administering or changing doses of psychotropic medications for certain residents. Health records showed that dose changes for antipsychotic and antidepressant medications were made without obtaining consent from the residents or their representatives. In one instance, a consent form was completed 26 days after the medication dose was increased, and staff were unable to provide evidence of email notifications or signed consent forms for these changes. Staff interviews further confirmed that consent was not obtained as required prior to medication administration or dose changes. The facility also failed to obtain consent before implementing safety devices such as bed rails, bolstered air mattresses, and tilt-in-space wheelchairs. Observations and record reviews revealed that these devices were in use for multiple residents without evidence of consent from the residents or their representatives. In one case, a resident with severe cognitive impairment and a healthcare Power of Attorney had a bed rail applied without the POA being notified or providing consent. Staff interviews indicated a misunderstanding of the consent process, with some staff believing that providing a copy of a safety assessment constituted consent, even though the forms did not document actual consent.