Failure to Obtain Consent Prior to Administering Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a mood stabilizer, specifically Depakote, to a resident with significant mental impairment and diagnoses including depression and coronary artery disease. The resident's medical record did not contain documentation of consent before the first dose of Depakote was given, despite the medication being ordered for major depressive disorder, recurrent, severe with psychotic symptoms. The facility's policy required that an informed consent discussion and completion of a consent form occur with the resident and/or their representative when starting a psychotropic medication or changing its dose. Interviews with facility staff revealed that the process for obtaining consent was not followed in this instance because staff considered Depakote primarily as an anti-seizure medication, not recognizing its use as a mood stabilizer required consent as a psychotropic medication. Both the LPN and the ADON confirmed that education and consent should be obtained prior to administration, but this step was missed. The consultant pharmacist verified that Depakote, when used as a mood stabilizer, is classified as a psychotropic medication and requires consent before administration.