Failure to Obtain Proper Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use by not properly obtaining and verifying informed consent for the administration of clonazepam and lorazepam. The resident in question was documented as lacking the mental capacity to make decisions, yet the consent for clonazepam was obtained directly from the resident, and the verification form indicated the resident as the person who provided consent. Additionally, the verification was obtained via telephone, and two nurses signed the form. For lorazepam, the informed consent form did not include the required information regarding the reason and duration for use, and the verification form lacked the name, dosage, and frequency of the medication. Further, the facility did not complete the Surrogate Interdisciplinary Team (IDT) Proposal of Medical Intervention for the resident, despite the absence of a family surrogate and the resident's inability to provide informed consent. The Director of Nursing confirmed that the resident could not make decisions and that the surrogate IDT proposal was not completed. The facility's policies required these steps to be followed to ensure proper informed consent for psychotropic medication use, but these procedures were not adhered to in this case.