Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed, written consent for the administration of psychotropic medications for one resident out of a sample of 32. According to the facility's policy, staff and physicians are required to review non-pharmacological alternatives, indications and rationale for medication use, potential risks and benefits, and the resident's right to accept or decline treatment before obtaining documented consent. However, for a resident admitted with a diagnosis of depression and assessed as cognitively intact, there was no evidence in the medical record that this process was followed prior to administering Sertraline and Lorazepam. Review of the resident's Medication Administration Records showed that both medications were administered as ordered by the physician over several months. During an interview, the resident stated they had never been provided with information about mood medications and denied taking any. Further review of the medical record confirmed the absence of documentation indicating the resident was informed of the risks and benefits or provided written, informed consent for the use of these psychotropic medications.