Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to obtain informed consent for the administration of Celexa, an antidepressant medication, to a resident diagnosed with depression. The resident, who was cognitively intact and had a history of paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure, was admitted to the facility and subsequently prescribed Celexa for depression manifested by low interest and motivation with activities of daily living. Review of the resident's records confirmed that informed consent was not documented prior to starting the medication. During an interview, the Quality Assurance Nurse acknowledged that informed consent had not been obtained before initiating the psychotropic medication, despite facility policy requiring that residents, families, or representatives be informed of the risks and benefits of such medications and that this information be documented in the resident's chart. The facility's policy specifically included antidepressants as psychotropic medications for which informed consent is required.
Plan Of Correction
F552 - Right to be informed/ Make Treatment Decisions How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/30/25, the Quality Assurance Nurse (QAN) offered and secured the consent from Resident 45 regarding the Celexa medication. (Exhibit #1) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/2/25, the Social Service Director (SSD) and QAN reviewed the list of residents with psychoactive medications orders to ensure that informed consents were signed and obtained. (Exhibit #2) - No other resident was affected of the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the licensed nurses regarding the facility's policy and procedure (P&P) titled "Use of Psychotropic Medications" dated 3/17/2025. (Exhibit #3) - Starting on 6/16/25, the SSD will conduct a weekly review for three months of the informed consents for those residents who will be receiving psychoactive medications orders. In addition, the SSD will review the informed consents of the newly admitted residents. (Exhibit #4) - Starting on 6/16/25, the SSD will report to the administrator any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The SSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025