Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including discussion of risks and benefits, for the use of psychotropic medications for four residents reviewed. For each of these residents, medical records showed prescriptions for various psychotropic drugs such as antidepressants, antipsychotics, and benzodiazepines, but lacked evidence that informed consent was obtained prior to administration. The records did not contain completed consent forms or documentation that residents or their representatives were informed about the risks, benefits, or alternatives to these medications, as required by facility policy. Interviews with facility staff, including the regional director of nursing, consulting pharmacist, and director of nursing, confirmed that consents for psychotropic medications had not been completed and that it was an expectation for such consents to be obtained. The facility's own policy required that residents, families, or representatives be informed of the benefits, risks, and alternatives to psychotropic medications before initiation or dose increases, and that this information be documented. Despite this, the review found no such documentation for the residents in question, all of whom had significant medical and psychiatric diagnoses and were prescribed multiple psychotropic medications.