Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to follow its own policy and procedure regarding informed consent for psychotropic medication administration for one resident diagnosed with major depressive disorder, hypertension, and dysphagia. The resident, who had severe cognitive impairment and required significant assistance with activities of daily living, was prescribed mirtazapine for depression. Review of the informed consent documentation revealed that while the resident's responsible party was provided information about the medication, the consent form lacked the physician's signature and did not include the date when staff witnessed the education being provided. Interviews with facility staff, including an LVN, the Social Services Director, and the Director of Nursing, confirmed that the consent was incomplete and not valid according to facility policy, which requires a physician's signature and proper dating of the witness to ensure that education about the risks and benefits of the medication was provided. The facility's policy also specifies that informed consent must be obtained and renewed every six months, and that the physician's signature may be obtained remotely if necessary. The incomplete documentation resulted in the resident potentially receiving a psychotropic medication without being fully informed as required.