Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper informed consent prior to administering psychotropic medications to multiple residents. In several cases, residents who lacked the capacity to make medical decisions were either asked to provide consent themselves or did not have a legally authorized representative involved in the consent process. For example, one resident with severe cognitive impairment and no listed emergency contact or next of kin was administered antipsychotic, antidepressant, and anticonvulsant medications after the facility obtained consent directly from the resident, despite documentation indicating the resident could not understand or make decisions. The Social Services Director and Director of Nursing both confirmed that the resident should not have been consenting and that a conservator should have been appointed to make such decisions. Another resident with an appointed Public Guardian (PG) received multiple psychotropic medications without the facility obtaining informed consent from the PG. The consent forms for these medications were incomplete, lacking documentation of who provided consent and the date it was obtained. The DON acknowledged that the PG was not given the opportunity to make an informed decision regarding the resident's care, as required. Additionally, a resident with severe cognitive impairment and no current emergency contacts had an outdated psychotropic consent form that was not renewed every six months as required, and a new consent was not obtained when a new medication order was placed. Further deficiencies included a resident who received a monthly antipsychotic injection without any signed or completed informed consent form, and another resident whose consent form for an antipsychotic medication was incomplete, missing the resident's name, date, and verification that consent was obtained. In each of these cases, facility staff acknowledged the failures to properly document and obtain informed consent, as required by facility policy and procedure. These actions resulted in residents or their representatives not being fully informed or able to make decisions regarding the use of psychotropic medications.