Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain an informed consent form for a psychotropic medication prescribed to a resident diagnosed with major depressive disorder. The resident, who demonstrated intact cognition as evidenced by BIMS scores of 15 and 14 on recent assessments, was receiving bupropion HCl daily for depression. Documentation in the resident's care plan and assessment area noted the use of antidepressant medication and the need to monitor for adverse effects, but there was no evidence of a signed informed consent for the psychotropic medication in the resident's electronic medical record. Observations confirmed the resident's daily activities and use of assistive devices, while interviews with facility staff revealed that only two other residents had consent forms on file for psychotropic medications. The administrative nurse acknowledged the absence of an informed consent for this resident, and a consultant confirmed that all psychotropic medications should have consent forms, noting that the necessary form had been sent to the administrative nurse previously. The facility was unable to provide a policy on informed consent for psychotropic medications.