Failure to Obtain Informed Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain informed consent prior to administering Ativan to a resident with severe cognitive impairment and anxiety disorder. The resident was admitted with chronic obstructive pulmonary disease and anxiety, and had an order for Ativan 0.5 mg every six hours as needed for anxiety manifested by restlessness. The medication was administered before the informed consent form was signed by the resident or their representative, as confirmed by the Director of Nursing, who acknowledged that consent should be obtained before giving any psychotropic medication. Additionally, the facility did not properly monitor and document manifested behaviors for the administration of Ativan and Seroquel for another resident with severe cognitive impairment, bipolar disorder, and chronic pain syndrome. The medication administration record showed that Ativan and Seroquel were given, but the required tallying of behavioral episodes was not completed as ordered. Instead of recording the number of episodes, only check marks were used, which did not provide the necessary information for the physician to assess the appropriateness of the medication. The facility's policy requires that psychotropic medications be used only after non-drug interventions have been attempted, and that all medications used to treat behaviors must be monitored for efficacy, risks, and adverse consequences. The policy also states that informed consent must be obtained prior to administration and that staff should use behavioral monitoring charts to track triggers, episodes, and responses. These procedures were not followed in the cases reviewed, resulting in deficiencies related to the use and monitoring of psychotropic medications.