Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Lexapro, for one resident. The resident, who had diagnoses including dementia, cognitive communication deficit, generalized muscle weakness, and major depressive disorder, was assessed as lacking the capacity to understand and make decisions. Despite this, the medical record showed that only the physician assistant and a licensed vocational nurse signed the informed consent form, with no signature or date from the resident's responsible party, who was designated to make medical decisions on the resident's behalf. The responsible party later confirmed that she had not provided informed consent and had not been adequately informed about the medication's potential side effects or complications by a qualified medical provider. The resident received Lexapro daily over several months, as documented in the medication administration records. Interviews with facility staff, including the LVN and the Director of Nursing, confirmed that the facility's policy required written informed consent for psychotropic medications and that this consent was not obtained from the responsible party. The failure to secure proper informed consent was acknowledged by staff and was not in accordance with the facility's established procedures.