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F0757
D

Lack of Consent for Psychotropic Medication

Charleston, West Virginia Survey Completed on 04-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a review of the medical record for one resident revealed a physician's order for Zoloft (Sertraline HCI) 50mg daily for anxiety disorder, but there was no signed consent form for this psychotropic medication in the resident's file. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required consent form for Zoloft was not present for the resident. The lack of a signed consent form indicated that the facility failed to ensure the resident's drug regimen was free from unnecessary medications, as required documentation was missing.

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