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F0552
D

Failure to Obtain Informed Consent from Authorized Responsible Party for Psychotropic Medications

Santa Cruz, California Survey Completed on 07-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent for psychotropic medications from the appropriate responsible party for a resident diagnosed with toxic encephalopathy and dementia. The resident's clinical record indicated that the responsible party was a conservator, but the informed consent for psychoactive medications was instead obtained verbally from a case worker. The case worker was listed as a contact but was not authorized to make medical decisions for the resident. Interviews with facility staff and the case worker confirmed that the conservator was the designated responsible party and that the case worker did not have the authority to provide consent for medical treatments. The facility's policy required that staff and physicians review treatment options and obtain documented consent from the resident or their representative prior to initiating or changing psychotropic medications, but this process was not followed in this instance.

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