Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain consent for the use of a psychotropic medication for one resident. According to the facility's policy, residents, families, or representatives must be involved in the medication management process, including being informed about the indication, dose, duration, and potential adverse consequences of psychotropic medications. In this case, a resident with generalized anxiety disorder and an invoked healthcare proxy was prescribed Ativan as needed prior to appointments. The resident's care plan referenced that psychotropic medication consent could be found in the medical record under consents. However, review of the medical record showed that there was no documentation indicating the healthcare proxy was informed of the new Ativan order or the associated risks and benefits before the medication was administered. The Medication Administration Record confirmed that Ativan was given prior to a medical appointment without documented consent from the healthcare proxy. Interviews with nursing staff and the Director of Nursing confirmed that consent is required before administering psychotropic medications, but this process was not followed in this instance.