Failure to Inform Resident of Risks and Benefits Before Initiating Psychotropic Medication
Penalty
Summary
A cognitively intact resident with diagnoses of anxiety disorder and major depressive disorder was admitted to the facility and subsequently started on Pristiq, a psychotropic medication, following a recommendation from a mental health nurse practitioner. Review of the resident's records, including the Minimum Data Set and physician's orders, confirmed the initiation of Pristiq. However, there was no documentation in the electronic medical record that the risks and benefits of Pristiq were reviewed with the resident prior to starting the medication. Interviews with facility staff, including the Social Services Assistant and the Director of Nursing, confirmed that there was no evidence of risk versus benefit education provided to the resident for the antidepressant medication. The facility's policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives before initiating any psychotropic medication. The resident also reported not knowing she was taking Pristiq and did not recall receiving any education about the medication prior to its initiation.