Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of a psychotropic medication for one resident. Specifically, a resident with diagnoses of dementia and depression, who was cognitively intact and required assistance with activities of daily living, was routinely administered citalopram for major depressive disorder. The resident's quarterly assessment indicated no significant depression or behavioral issues. Despite this, there was no signed consent form in the resident's medical record outlining the risks, benefits, and alternative treatments associated with the psychotropic medication. Interviews with facility staff, including a registered nurse, the DON, and the administrator, confirmed that the required consent process had not been completed for this resident. Facility policy requires that staff provide residents or their representatives with information about the indication, dose, side effects, adverse consequences, and treatment goals for psychotropic medications, and that informed consent be obtained and documented in the medical record. This process was not followed in this instance.