Failure to Obtain Informed Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medication use, as required by policy and regulation. For one resident with depression and schizoaffective disorder, Belsomra was prescribed and administered for insomnia without obtaining informed consent, without monitoring for sleep or side effects, and without a care plan that addressed the medication's use or related interventions. The Director of Nursing confirmed that there was no documentation of informed consent, no monitoring after the medication was started, and the care plan did not include specific interventions related to Belsomra. For another resident with bipolar disorder and schizophrenia, the dose of the antipsychotic medication Perphenazine was increased without obtaining updated informed consent for the new dosage. The DON verified that the consent on file was for a different dose than what was being administered. Facility policy required that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing psychotropic medications, and that such information be documented, but this was not followed in these cases.