Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks and benefits of psychotropic medications for five residents who were prescribed such medications. Clinical record reviews, policy review, and staff interviews revealed that, despite facility policy requiring notification and consent for the initiation, increase, or decrease of psychoactive medications, there was no documentation that this information was provided to the residents or their representatives. The affected residents had various diagnoses, including dementia, anxiety, depression, diabetes, osteoarthritis, asthma, chronic obstructive pulmonary disease, hemiplegia, and insomnia, and were prescribed medications such as sertraline, trazodone, olanzapine, alprazolam, duloxetine, buspirone, and Tylenol PM. The review of medical records and order summaries for these residents showed that psychotropic medications were administered without documented evidence that the residents or their responsible parties were informed of the associated risks and benefits prior to administration. Interviews with facility staff, including the DON, confirmed the absence of consent forms for these medications, and there was an acknowledgment that the pharmacist would assist in completing them. This lack of documentation and communication represents a failure to comply with facility policy and regulatory requirements regarding informed consent for psychotropic medication use.