Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, for the use of psychotropic medications for four residents. For each resident, medical records showed administration of psychotropic medications such as lorazepam, haloperidol, quetiapine, duloxetine, citalopram, and sertraline, but lacked evidence of signed consent forms or documentation that the risks, benefits, and alternatives were discussed with the resident or their representative prior to starting the medications. In several cases, there was also no documentation of education provided regarding the medications. Residents affected included individuals with varying degrees of cognitive impairment and complex medical histories, such as memory impairment, hallucinations, depression, dementia, and other chronic conditions. Some residents were on hospice care or had significant behavioral symptoms, while others were cognitively intact but still did not have documented consent for psychotropic medication use. Medication administration records confirmed that these medications were given as ordered, and progress notes did not reflect any discussion or education about the medications. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed a lack of clarity regarding responsibility for obtaining consent and providing education about psychotropic medications. Staff indicated that direct care nurses rarely, if ever, obtained consent or discussed risks and benefits, and there was no consistent process in place. The facility was unable to provide a policy on residents' rights regarding medications when requested.