Failure to Obtain Informed Consent and Inform Residents of Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to participate in their care and treatment, specifically regarding medication administration and informed consent for psychotropic medications. For one resident with diagnoses including post-traumatic stress disorder and schizophrenia, the facility did not obtain a complete informed consent for the administration of Zyprexa, a psychotropic medication. The consent form lacked the physician's signature and did not specify the dose frequency. According to facility policy, the physician's signature is required to confirm that the risks and benefits of the medication were explained to the resident or their responsible party. The resident's records indicated that while the individual could make needs known, they could not make medical decisions, further emphasizing the importance of proper consent procedures. Additionally, during medication administration observations, a nurse failed to inform two residents of the names and indications of several medications prior to administration. The nurse admitted to not providing this information because the medication cups were not clearly labeled, which prevented the residents from being informed about their treatment and making choices such as refusing specific medications. The Director of Nursing confirmed that this omission was contrary to facility policy and restricted the residents' rights to be informed and involved in their care. The facility's own policies require that residents be informed in advance about the care and treatments they will receive, including the names and purposes of medications, and that informed consent be obtained for psychotropic medications. The failure to follow these procedures resulted in residents not being fully informed or able to participate in decisions regarding their care, as evidenced by the lack of proper consent documentation and the omission of medication information during administration.