Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to understand their health status, care, and treatments, specifically regarding the use of psychotropic medications. For one resident with diagnoses including Alzheimer's disease, dementia, and mood disorder, the informed consent documented was for Depakene Oral Solution, while the actual physician's order and administration were for Depakote Oral Tablet Delayed Release. Staff interviews confirmed that the consent form did not match the medication preparation being administered, and a new consent was not obtained when the medication form was changed. This discrepancy was acknowledged by nursing staff, who stated that a new consent should have been obtained from the resident's representative to honor the resident's right to informed consent. For another resident with insomnia and depression, the facility failed to obtain informed consent from the resident or their responsible party prior to the administration of psychotropic medications, specifically citalopram and trazodone. The resident's responsible party reported not being contacted by the facility to discuss the risks, benefits, or alternatives to these medications before they were started. Facility documentation and staff interviews confirmed that there was no record of education or consent being provided prior to the initiation of these medications. Facility policies reviewed indicated that it is the responsibility of the attending healthcare practitioner to inform the resident or their representative about the initiation, reason for use, and risks associated with psychotropic medications, and that informed consent must be obtained prior to starting such medications. The failure to follow these policies resulted in residents or their representatives not being given the opportunity to make informed decisions regarding the use of psychotropic medications.