Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided with informed consent regarding the use of psychotropic medications. Specifically, three residents with diagnoses including schizophrenia, anxiety, bipolar disorder, and depression were administered antipsychotic, antianxiety, and antidepressant medications without proper documentation of informed consent prior to the initiation or change of these medications. In one case, a resident received Seroquel and Zyprexa for schizophrenia and clonazepam for anxiety, but the informed consent for these medications was either delayed or incomplete, with some consents signed months after the medications were started and others missing entirely for as-needed orders. Another resident with anxiety and bipolar disorder was prescribed clonazepam, desvenlafaxine, lamotrigine, and Latuda, but the electronic medical record lacked any documentation of informed consent for these psychotropic and antipsychotic medications. Similarly, a third resident with anxiety and depression was prescribed lorazepam and mirtazapine, yet there was no evidence of informed consent for these medications in the medical record. Interviews with administrative and licensed nursing staff confirmed that facility policy required informed consent to be obtained before starting or changing psychotropic medications, but this was not consistently followed. Observations and record reviews revealed that the facility's own policy mandated obtaining informed consent from residents or their representatives prior to the administration of antipsychotic medications. Despite this, the required consents were either missing, delayed, or incomplete for multiple residents receiving high-risk psychotropic drugs. Staff interviews further verified that the process for obtaining and documenting informed consent was not adhered to as required by facility policy.