Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. One resident with moderate cognitive impairment and diagnoses including traumatic brain injury and bipolar disorder was receiving Haldol, an antipsychotic medication, without any documented informed consent in the electronic medical record. Staff interviews confirmed that no signed consent or documentation of education regarding the need, risks, benefits, or alternatives to the medication was present for this resident. The process for obtaining informed consent was described as a responsibility of providers and nursing staff, but audits by social services did not reveal any evidence of consent for the medication in question. Another resident, who was cognitively intact and had a diagnosis of anxiety, was prescribed Xanax on an as-needed basis, also without any documented informed consent in the medical record. The DON confirmed that no consents were obtained for either the Haldol or the PRN Xanax. Review of facility policies showed that while one policy addressed physician responsibilities regarding antipsychotic medication use, it did not include requirements for informing residents or their representatives about the need for the medication or its risks and benefits. Another policy stated residents have the right to be informed about their condition and treatment options, but this was not followed in these cases.