Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the treatment being provided, specifically regarding the use of a psychotropic medication. The facility's policy required that residents be fully informed prior to initiating or increasing a psychotropic medication. However, a review of the consent form for the use of Aripiprazole (Abilify), an antipsychotic medication prescribed for bipolar disorder, revealed that the form was incomplete. The consent form did not include the dosage or the diagnosis for which the medication was prescribed. The resident involved had diagnoses of bipolar disorder and borderline personality disorder and was responsible for making her own medical decisions. Interviews with facility staff, including a licensed nurse and the administrator, confirmed that the consent form was missing required information and was not properly completed. This omission meant the resident was not fully informed about her treatment as required by facility policy.