Failure to Obtain Consent and Develop Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to follow its own policy regarding the use of psychotropic medications by not obtaining informed consent and not developing individualized care plans for several residents. Specifically, five residents with various diagnoses, including schizoaffective disorder, depression, schizophrenia, and dementia, were administered psychotropic medications such as Olanzapine, Mirtazapine, Quetiapine, Risperidone, Lithium Carbonate, and Sertraline without documented consent. In multiple cases, the electronic health records lacked both the required consent forms and care plans for these medications, despite facility policy mandating these steps prior to administration. Direct interviews with staff, including registered nurses, the Director of Nursing, the care plan coordinator, and the Social Service Director, confirmed that the expectation is to obtain consent before administering psychotropic medications. Staff acknowledged that medications should not be given without consent and that care plans should be individualized and documented in the resident's health record. However, when surveyors requested documentation, the facility was unable to provide the necessary consents for the affected residents, and in some cases, care plans were also missing. One resident, who was cognitively intact, reported that neither she nor her family gave consent for a newly prescribed psychotropic medication and that she received the medication without their approval. Staff confirmed that the medication was on hold due to the lack of consent. The facility's own policies require informing residents or their representatives about psychotropic medications, obtaining verbal or written consent prior to initiation, and developing a comprehensive care plan that includes treatment goals and non-drug interventions. Despite these requirements, the facility did not adhere to its policies for the residents identified in the report.