Failure to Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of psychotropic medications for one resident with diagnoses including cognitive communication deficit, anxiety, and dementia. The resident had severely impaired cognition and was dependent on staff for all activities of daily living. Multiple physician orders for lorazepam, an anti-anxiety medication, were issued with varying dosages, frequencies, and routes of administration over several months. However, there was no documented informed consent for several of these orders, specifically for those dated 6/15/2025 to 6/16/2025 and 7/13/2025 to 7/21/2025, as confirmed by the Medical Records Director. The only informed consent obtained in 2025 was for a later order starting 7/22/2025. Interviews with facility staff, including the Medical Records Director and the Director of Nursing, confirmed that informed consents should be stored in the electronic medical record and that new consents are required when there is a change in the frequency or route of psychotropic medication administration. Facility policy also requires written informed consent for psychotropic medications, to be renewed every six months and placed in the resident's medical record. Despite these policies, the required consents were not present for the specified medication orders, resulting in a failure to ensure the resident or their responsible party was informed about the medication's use and potential adverse effects.