Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and provided informed consent regarding the use of psychotropic medications, as required by facility policy. Multiple residents with diagnoses such as PTSD, anxiety, depression, panic disorder, bipolar disorder, and dementia were prescribed various psychotropic medications, including antianxiety agents, antidepressants, and antipsychotics. Despite these prescriptions, the electronic medical records (EMRs) and electronic health records (EHRs) for these residents lacked documentation that informed consent was obtained or that education was provided about the medications' benefits, risks, and alternatives. For example, one resident with PTSD, anxiety, and depression was prescribed lorazepam, mirtazapine, and sertraline, but there was no evidence in the EMR of informed consent for these medications. Another resident with panic disorder, major depressive disorder, and bipolar disorder was prescribed buspirone, desvenlafaxine, lorazepam, and olanzapine, again without documentation of informed consent. Additional residents with depression, adjustment disorder, insomnia, and dementia were also prescribed psychotropic medications such as bupropion, citalopram, and duloxetine, with no evidence that they or their representatives were informed about the medications or provided consent. Interviews with facility staff confirmed that informed consent for psychotropic medications had not been completed for these residents. The administrative nurse indicated a misunderstanding of the facility's policy, believing that consent was only necessary for new medications started at the facility, not for those continued upon admission. The facility's policy, however, clearly required informing residents, families, or representatives of the benefits, risks, and alternatives for each psychotropic medication prior to adding, discontinuing, or changing any such medication.