Failure to Ensure Proper Informed Consent and PRN Psychotropic Medication Documentation
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a documented inability to make medical decisions was not permitted to sign informed consent forms for psychotropic medications. Specifically, the resident, who had diagnoses including schizophrenia, unspecified intellectual disabilities, and a cognitive communication deficit, was found to have signed his own consent for both antipsychotic and antidepressant medications. The Director of Nursing confirmed that the resident did not have the capacity to provide informed consent, as indicated in the resident's history and physical, and that the consent obtained was therefore invalid. Additionally, the facility did not ensure that another resident's PRN psychotropic medication order included a specific duration or stop date, nor did it document a clinical reason for extending the order beyond 14 days. The resident, who had diagnoses of unspecified dementia, anxiety disorder, and depression, was not capable of making medical decisions. The order for clonazepam was written as PRN with an indefinite end date and lacked documentation of a specific treatment duration or rationale for continuation beyond the standard 14-day limit. Both the LVN and the consultant pharmacist acknowledged that the order should have included a stop date or specified duration, and the facility's policy required such documentation. The facility's own policy stated that PRN orders for psychotropic drugs are limited to 14 days unless the prescriber documents a rationale for extension and indicates the duration. The policy also required verification of informed consent prior to administration of psychotropic medications. In both cases, the facility failed to follow its own procedures and regulatory requirements, resulting in deficiencies related to the use and documentation of psychotropic medications.