Failure to Obtain and Document Consent for HIV Prophylaxis Medication
Penalty
Summary
The facility failed to obtain and document consent for participation in a pharmacy program involving the administration of Descovy for HIV pre-exposure prophylaxis for four residents. These residents, who had varying diagnoses including hypertension, kidney disease, schizoaffective disorder, epilepsy, diabetes, and depression, were all found to have received Descovy as per physician orders. Despite being cognitively intact or only moderately impaired, none of the residents were aware they were taking this medication, nor had they received any information or education about it. Interviews with the residents confirmed their lack of awareness and consent, with some explicitly stating they would not have agreed to take the medication if informed. Record reviews revealed that there was no documentation of consent, education, or individualized care plans related to the pharmacy program or the administration of Descovy in any of the residents' medical records. The Certified Nurse Consultant acknowledged that written consent was not obtained and that there was no documentation of resident agreement in the medical records. Additionally, there were no separate assessments documenting risk factors for each resident, and individualized care plans were still in development. The facility's Medical Doctor stated that consent, education, and explanation of risks and benefits should have been provided prior to administering the medication, which was not done.