Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to notify a resident representative of the risks and benefits associated with the initiation of a new psychotropic medication for one resident. According to the facility's policy, staff and the physician are required to review the indications, rationale, potential risks and benefits, and alternative treatment options with the resident or their representative prior to obtaining documented consent or refusal. In this case, a psychiatric nurse practitioner recommended starting Rexulti 0.5 mg for a resident diagnosed with Alzheimer's disease due to recent combative behavior. The staff contacted the resident's representative to inform her of the new medication order and explained that the medication was for Alzheimer's and to treat agitation. However, there was no documentation that the representative was informed of the potential risks and benefits of Rexulti, alternative treatment options, or that informed consent was obtained. The Director of Nursing confirmed during an interview that the representative was not provided with this information or the opportunity to consent or refuse the treatment. The resident involved had a history of dysphagia following cerebral infarction and Alzheimer's disease, and was rarely or never understood, as indicated by the Minimum Data Set assessment.