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F0552
D

Psychotropic Medication Administered Without Court-Approved Consent

Newton, Massachusetts Survey Completed on 07-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain legal informed consent from the court prior to administering a psychotropic medication, Fluphenazine, to a resident with a court-appointed guardian and an existing court-approved treatment plan. The resident, who was admitted with schizoaffective disorder and demonstrated intact cognition, was administered Fluphenazine over several days as ordered by the physician. However, a review of the Roger's treatment plan, which authorizes specific antipsychotic medications for the resident, did not include Fluphenazine among the approved or alternative medications. Interviews with facility staff and the court-appointed Roger's Monitor confirmed that Fluphenazine was given without prior court authorization, as required by the treatment plan and facility policy. The facility's policy mandates that legal informed consent must be obtained before initiating or changing psychotropic medications, including reviewing non-pharmacological alternatives and potential risks with the resident or their representative. The failure to secure court approval for Fluphenazine administration constituted a breach of this policy and legal requirements.

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