Failure to Obtain Informed Consent for Psychotropic Medication Dosage Change
Penalty
Summary
The facility failed to inform a resident and/or the resident's representative about the risks associated with psychotropic medications, specifically regarding a change in the dosage and frequency of clonazepam. The resident had a history of multiple psychiatric and neurological diagnoses, including unspecified psychosis, neuroleptic-induced parkinsonism, extrapyramidal and movement disorders, schizophrenia, schizoaffective disorder, and anxiety disorder. The resident's cognitive status varied over time, with documented severe cognitive impairment at one point and cognitive intactness at another. The care plan indicated the use of antipsychotic and antianxiety medications, and interventions included administering medications as ordered, monitoring for side effects, and communicating with the family and physician about ongoing medication needs. A review of the electronic health record showed that while there was a signed psychotropic consent for clonazepam at a lower dose, there was no evidence that the resident or representative was informed or provided consent for a subsequent increase in the medication's dosage and frequency. Interviews with administrative nursing staff revealed a belief that updated consent was not necessary for dosage changes if the medication itself remained the same, and that informed consent could be obtained verbally rather than in writing. The facility's policy stated that psychotropic medications should be administered based on comprehensive assessment and with proper documentation, but the required education and consent for the medication change were not present in the record.