Failure to Obtain and Document Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that a resident and the resident's representative were informed of the risks and benefits associated with the use of psychotropic medications prior to the initiation of treatment. Observation showed the resident ambulating slowly with a walker and requiring staff direction. Review of the resident's physician orders revealed administration of Seroquel, olanzapine, and sertraline for conditions including sleeplessness, agitation, and mild dementia with psychotic disturbance. Examination of the electronic health record did not show documentation that the risks and benefits of these medications were discussed with or provided to the resident or their representative. Staff confirmed that the process for obtaining consent with documented risks and benefits was inconsistent, particularly when the responsible staff member was unavailable, and no consent documents were provided for review during the survey period.