Failure to Inform Residents and Obtain Timely Consents for Care and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed about their health status, care, and treatments upon admission, as well as about the risks and benefits of psychotropic medications prior to their use. For four out of five sampled residents reviewed for admission, there was no documentation that the Admission Agreement or supporting documents had been reviewed or discussed at the time of admission. These residents included individuals with diagnoses such as muscle weakness, bacterial blood infection, dementia, failure to thrive, weakness, wound infection, and hip fracture. Some of these residents were cognitively intact and able to verbalize their needs, while others had severe cognitive impairment. Interviews with residents confirmed that they were not informed about the type of care they would receive or who would provide it, and they did not recall signing any consent forms for care and treatment. A review of facility records revealed that, out of 36 admissions in the past 30 days, only two admission packets contained a consent for routine nursing care or other services. Staff interviews indicated uncertainty about the required timeframe for completing admission consents, and staff acknowledged that residents would not be fully informed if admission documents were not reviewed in a timely manner. The facility had identified that admission documents and consents were not being completed on time, partly due to staffing vacancies, including the absence of an Admissions Director/Coordinator. The facility also failed to obtain informed consent for psychotropic medications prior to administration for three of five sampled residents reviewed for unnecessary medications. In one case, a resident's representative was not contacted for consent before an antipsychotic medication was administered, and the medication was later discontinued after the representative declined it. In another case, a resident received a psychotropic medication before the consent was completed, and in a third case, consents for psychotropic medications were obtained 49 days after the medications had already been administered. Additionally, the consents did not include information about serious side effects or black box warnings. Staff interviews confirmed that consents should have been obtained prior to the first dose of medication.