Failure to Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent prior to administering psychotropic medication (temazepam) to a resident who had the mental capacity to make their own decisions. According to the facility's policy, licensed nurses are required to verify and document informed consent in the resident's medical record before administering the first dose of such medications. Medical record reviews showed that multiple orders for temazepam were initiated and administered over several months, but the records did not contain evidence that informed consent was obtained for these orders. Additionally, one consent form present in the record did not indicate who provided the consent. Interviews with nursing staff confirmed that for each new or changed order of PRN psychotropic medication, a new consent should have been obtained and documented. Both an RN and an LVN reviewed the resident's records and verified the absence of required informed consent documentation for several temazepam orders. This deficiency was identified through interviews, medical record reviews, and review of facility policy and procedures.