Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain proper informed consent for the use of psychotropic medications for one resident with impaired cognition and multiple complex medical diagnoses, including dementia, encephalopathy, anxiety, depression, and visual hallucinations. The resident required assistance with activities of daily living and was prescribed lorazepam and risperidone for agitation, anxiety, and delirium. Record review showed that lorazepam was administered multiple times with documented effectiveness, and risperidone was started and administered according to the medication administration record. However, there was no documentation in the medical record that informed consent had been obtained from the resident's responsible party upon admission or when changes were made to medication dosing or frequency. Interviews with the DON confirmed that informed consent for psychotropic medications is expected to be completed within the first week of admission and updated with any new medications or changes in dosage. Despite this policy, the required documentation for informed consent for both lorazepam and risperidone could not be located in the resident's medical record or uploaded files. The facility's own policy mandates obtaining and documenting informed consent, including education on medication indications, side effects, risks, and benefits, as well as notification of dose changes, but these steps were not followed in this case.