Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for a resident diagnosed with dementia and anxiety disorder. The resident was assessed as having the capacity to understand and make decisions, with moderately impaired cognition noted in the Minimum Data Set. Despite a physician's order for Ativan to be administered twice daily for anxiety, a review of both the paper and electronic health records revealed that no informed consent form for the use of Ativan was present for the relevant period. Both the Medical Records staff and the Registered Nurse Supervisor confirmed the absence of the required documentation, and the Director of Nursing also verified that the consent form could not be located in the resident's records. Facility policy required that informed consent be obtained and documented before administering psychoactive medications, with written consent to be renewed every six months. The lack of a signed and dated consent form for the psychotropic medication was acknowledged by staff as a violation of resident rights and a failure to follow established procedures. The deficiency was identified through interviews, record reviews, and policy examination, all confirming that the necessary informed consent process was not completed or documented as required.