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F0552
D

Failure to Update Informed Consent for Psychotropic Medication Changes

Big Bear Lake, California Survey Completed on 05-08-2025

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

The facility failed to ensure that residents or their representatives were properly informed and provided updated informed consent for changes in psychotropic medication orders. For three residents, documentation showed that either the consent forms did not reflect new medication orders or dosage changes, or the consent forms did not match the current physician orders. Specifically, one resident had new orders for Trazodone and Aripiprazole, but the consent on file was for different dosages and was not updated. Another resident had new orders for Escitalopram and Risperidone, but the consents on file reflected previous dosages and were not updated to match the current orders. Additionally, a third resident had a consent form for Abilify at a lower dosage than what was currently ordered by the physician, and the consent did not match the physician's order. In each case, staff interviews confirmed that updated consents reflecting the current medication regimens could not be found. The facility's own policy required that informed consent be updated with any change in psychotropic medications, but this was not followed. As a result, the residents and their representatives were not informed of the risks, benefits, adverse reactions, or their right to refuse the administration of the new or changed psychotropic medications. This failure violated the residents' rights to be fully informed about their care and treatment, as required by facility policy and regulatory standards.

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