Failure to Provide and Document Complete Psychotropic Medication Information
Penalty
Summary
The facility failed to adequately inform several residents and/or their representatives about the specific risks, benefits, and alternatives associated with their prescribed psychotropic medications. In multiple cases, the consent forms provided to residents only listed the general class of medication (such as antidepressant, antipsychotic, or antianxiety) and potential side effects for the class, but did not include the names of the individual medications, their prescribed dosages, or the specific reasons for their use. This lack of detailed information was observed in the records of residents with varying degrees of cognitive function, including those with intact cognition and those with moderate to severe cognitive impairment. For example, one resident with diagnoses including altered mental status, metabolic encephalopathy, and anxiety disorder had a consent form that omitted the names and dosages of prescribed medications such as Buspar and Cymbalta. Another resident with borderline personality disorder, cerebral palsy, and major depressive disorder was prescribed multiple psychotropic medications, but the consent form again lacked specific medication names and dosages. In both cases, administrative staff confirmed that while residents were verbally informed about their medications, this education was not documented in the medical record as required by facility policy. Additional residents with diagnoses such as schizophrenia, alcohol-induced dementia, and depression were also found to have incomplete psychotropic consent documentation. In some instances, residents expressed confusion or dissatisfaction regarding their medications, with one resident stating they were told an antidepressant would help with pain, but it was not effective. The facility's policy required that residents and/or their representatives be informed and that this communication be documented, but this was not consistently done, leading to the deficiency.