Failure to Obtain Informed Consent from Health Care Proxy for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the health care proxy (HCP) for a resident with dementia and depression was notified of the benefits, risks, and alternatives prior to the administration of a psychotropic medication. According to the facility's policy, written informed consent from the resident or their legally authorized representative is required before starting psychotropic medications. The resident in question had an HCP invoked and was prescribed Sertraline, an antidepressant, which was administered as ordered. A review of the resident's medical records, including both electronic and paper files, did not show any documentation that the HCP was informed about the medication's benefits, risks, or alternatives. Interviews with nursing staff and the unit manager confirmed that the required consent form was not present in the resident's record and that the HCP should have signed a consent form before the medication was initiated. The absence of this documentation indicates that the facility did not follow its own policy regarding informed consent for psychotropic medication administration.