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F0552
D

Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration

Anaheim, California Survey Completed on 05-21-2025

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 prior to administering new or increased psychotropic medications for two residents. For one resident, trazodone was administered for depression before informed consent was obtained, as documented by a physician's order and a subsequent consent form completed after the medication had already been started. The Assistant Director of Nursing (ADON) confirmed that the medication was given prior to obtaining the required consent. For another resident with moderately impaired cognition and a diagnosis of schizoaffective disorder, quetiapine fumarate was ordered and administered in two different dosages. While informed consent was obtained for the 100 mg bedtime dose, there was no documentation of informed consent for the 50 mg daily dose, despite the medication being administered regularly. The ADON and Administrator both verified that the required consent for the 50 mg dose was not present in the medical record.

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