Failure to Obtain Conservator Consent for Antipsychotic Medication Change
Penalty
Summary
The facility failed to inform the court-appointed conservator of a resident with schizophrenia about the risks, benefits, and alternatives to a proposed medication change, as required by both facility policy and the resident's legal status. The resident, who was under an LPS conservatorship due to a serious mental illness and inability to make medical decisions, was admitted to the facility while receiving Clozapine for schizophrenia. Shortly after admission, Clozapine was placed on hold for an unknown reason, and the resident was instead prescribed Paliperidone. The informed consent form for Paliperidone was signed by the resident and staff, but not by the conservator, who was the legally authorized decision-maker. Facility records and interviews confirmed that the conservator was not notified or consulted prior to the medication change or discontinuation of Clozapine. Staff interviews revealed uncertainty about why the medication was held and acknowledged that the conservator's consent was not obtained, despite the resident's long-standing conservatorship and the facility's own policies requiring such notification and consent for psychotropic medication changes. The conservator was only made aware of the situation after the resident's mental health had deteriorated. As a result of the lack of communication and failure to obtain proper consent, the resident experienced a decline in mental health status, necessitating hospital readmission for treatment of schizophrenia. Documentation did not provide a rationale for the medication change, nor did it show that the conservator was informed or involved in the decision-making process, as required by both policy and legal mandate.