Failure to Obtain Informed Consent for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to obtain proper informed consent for the administration of antipsychotic and mood-stabilizing medications for a resident diagnosed with schizophrenia and bipolar disorder. Upon review, the resident was readmitted with orders for risperidone, quetiapine (Seroquel), and valproic acid. Documentation showed that the resident had impaired memory recall and lacked the capacity to make medical decisions, as indicated in both the History and Physical and the Minimum Data Set. Despite this, the facility's consent forms for these medications only indicated verbal consent from the resident, with no signature from either the resident or a responsible party. Interviews with the DON and Medical Director confirmed that the resident did not have the capacity to provide informed consent and that the facility did not obtain consent from the resident's representative. The facility's policy required that informed consent be obtained from the resident or their representative prior to administering psychotropic medications, including a review of risks, benefits, and alternatives. The consent forms were completed inaccurately and did not reflect the resident's cognitive status or the need for a representative's involvement.