Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from residents or their responsible parties prior to initiating new psychotropic medications for multiple residents. In several cases, residents with cognitive impairments or conservators were started on medications such as antidepressants and antipsychotics without documented consent. For example, one resident with severe cognitive impairment and a conservator began receiving an antidepressant, but there was no evidence that the conservator was informed or provided consent before the medication was administered. Consent was only obtained over 100 days after the medication was started, and the form was not properly signed by the staff member who obtained it. Other residents, including those with dementia, schizophrenia, and anxiety disorders, were also started on various psychotropic medications without timely or properly documented consent. In some instances, verbal consent was obtained long after the medications had been initiated, and forms lacked signatures from the staff who obtained the consent. Staff interviews revealed confusion and lack of awareness regarding the process for obtaining and documenting informed consent, with some staff members unaware of the facility's policy on psychotropic medications. The facility's own policy required that consent be obtained from the resident or responsible party when starting a psychoactive medication and that they be notified of any dose changes. However, the policy was not consistently followed, and staff responsible for obtaining consent were not always familiar with the procedures. Documentation and interviews confirmed that the deficiency was systemic, affecting multiple residents and involving delays and omissions in the consent process.