Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of a psychotropic medication, Lamotrigine, for one resident. The resident was admitted with diagnoses of Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. A review of the resident's medical record and order summary showed that Lamotrigine had been prescribed and administered without a corresponding informed consent form present in the record. The Social Services Assistant confirmed that no informed consent had been obtained for this medication. Further confirmation was provided by the Consultant Pharmacist, who stated that informed consent was required prior to administering Lamotrigine. The facility's own policy and procedure on informed consent, dated February 2025, specifies that written informed consent must be obtained by the prescribing physician or licensed healthcare practitioner and recorded in the resident's medical record before initiating treatment with psychotherapeutic drugs. This policy was not followed in the case of this resident.