Antipsychotic Medication Administered Without Court Approval
Penalty
Summary
The facility failed to ensure that an advance directive, specifically a court-approved Roger's treatment plan, was properly expanded before administering a new antipsychotic medication to a resident. The resident, who had a diagnosis of schizoaffective disorder and was cognitively intact, had a court-appointed guardian and a Roger's treatment plan in place that outlined which antipsychotic medications were authorized for use. However, Fluphenazine, the antipsychotic medication administered to the resident over several days, was not included in the list of approved or alternative medications in the current Roger's treatment plan. Interviews with facility staff, including the Regional Social Worker and the Director of Nurses, confirmed that the medication should not have been administered without first obtaining court approval to expand the Roger's treatment plan. The court-appointed Roger's monitor was also unaware that court approval was required for the new medication. This sequence of events resulted in the administration of an antipsychotic medication without the necessary legal authorization as required by the resident's advance directive and court order.