Failure to Provide Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident or the resident's representative about the risks, benefits, and alternatives associated with the use of psychotropic medications, specifically lorazepam and Seroquel. The resident in question had a history of Pick's Disease, unspecified dementia with behavioral disturbance, and anxiety disorder, and was noted to have severe cognitive impairment and behavioral symptoms. Documentation in the Electronic Health Record (EHR) showed orders for Seroquel and lorazepam, both scheduled and as needed, but lacked evidence that education or informed consent regarding the use of lorazepam was provided to the resident or their representative. Interviews with nursing staff confirmed that it was their responsibility to provide education and obtain informed consent prior to initiating or changing psychotropic medications, but in this case, no such documentation was present. The administrative nurse acknowledged the absence of informed consent documentation and noted that the provider had refused to provide medication education to the resident's representative. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives of psychotropic medications prior to initiation or dosage changes, but this was not followed for this resident.