Failure to Obtain Written Consent for Psychoactive Medication Administration
Penalty
Summary
The facility failed to obtain valid written consent for the administration of a psychoactive medication, Seroquel 25 mg, for a resident with schizoaffective disorder and bipolar disorder. Although there was a signed consent form for Seroquel 50 mg, there was no written consent on the required HHSC Form 3713 for the 25 mg dosage that was actively being administered. The resident had a moderately impaired cognition, as indicated by a BIMS score of 10, and was taking antipsychotic medication daily during the review period. The care plan documented the use of psychotropic medication for schizophrenia and psychotic disorder, with interventions to administer medications as ordered and consult with pharmacy. Interviews with the ADON and Administrator revealed that responsibility for obtaining the correct psychotropic medication consents rested with the ADON and DON. The ADON acknowledged that the consent for the correct medication and form was present, but the dosage did not match the current order, and this discrepancy was missed during recent audits. The facility did not provide a policy regarding psychotropic medications when requested by surveyors.