Incomplete Psychotropic Medication Consent for Resident
Penalty
Summary
The facility failed to obtain a completed psychotropic medication consent for one of six sampled residents. Interviews with nursing staff confirmed that psychotropic medication consents are required to include the resident's name, medication, dosage, route, and frequency, and must be signed by the physician. Record review for a resident with diagnoses including schizoaffective disorder and major depressive disorder, who was severely cognitively impaired and dependent on staff for all activities of daily living, showed that the resident was receiving Zyprexa Zydis via gastrostomy tube as ordered by the physician. However, the Facility Verification of Resident Informed Consent form for this resident, dated prior to the medication administration, was missing the required dosage and frequency information for Zyprexa Zydis. The facility's policy and procedure on informed consent specifies that the nature of the procedure, including probable frequency and duration, should be presented to the resident prior to obtaining consent. This omission resulted in the resident receiving psychotropic medication without a fully completed and compliant informed consent.