Psychotropic Medication Administered Without Prior Consent
Penalty
Summary
A resident with diagnoses including atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit was admitted to the facility. The resident had impaired cognition as indicated by a BIMS score of 10 and no recent depressive symptoms per the Resident Mood Interview. The care plan included administration of antidepressant medication for depression. An order for Bupropion HCL Extended Release for anxiety was initiated, and the medication was administered to the resident over a three-day period. However, the required informed consent for the psychotropic medication was not obtained prior to administration. The resident's representative declined consent for Bupropion after the medication had already been given. Interviews with facility staff, including an LPN, the clinical resource, and the DON, confirmed that facility policy mandates obtaining psychotropic medication consent before administration, and this expectation was not met in this case. Facility policies also state that residents have the right to be informed and to decline treatment with psychotropic medications.