Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were informed of the risks and benefits of a prescribed psychotropic medication, specifically Sertraline, prior to its administration. Clinical record review showed that while consents were obtained for other antidepressant medications (Duloxetine and Trazodone), there was no documented consent for Sertraline. The resident, who had multiple diagnoses including type II diabetes, depression, anxiety, left leg amputation, thrombosis, insomnia, and chronic pain, was prescribed Sertraline in addition to other antidepressants. The care plan indicated that education about medication risks and benefits should be provided, but there was no evidence in the clinical record that this occurred for Sertraline. Interviews with facility staff, including an LPN and the DON, confirmed that the facility's process requires obtaining consent and educating residents or their representatives before administering psychotropic medications. Both staff members verified that no consent for Sertraline was present in the resident's chart, and there were no progress notes documenting that the resident or representative had been informed about the medication. Facility policy also requires consent prior to administration of psychoactive medications, but this was not followed in the case of Sertraline for this resident.