Failure to Inform Residents and Representatives of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents and their representatives were fully informed about the risks, benefits, options, and alternatives of psychotropic medications prior to starting or changing such medications. For two of five sampled residents, documentation and interviews revealed that no risk versus benefit information was provided or discussed in plain language, and there was no evidence that residents or their representatives signed or received any such information. Instead, the facility only documented that family members were notified of medication changes in the progress notes, without specifying the content of those discussions. One resident, who was cognitively intact and had multiple complex diagnoses including breast cancer, diabetes, hypertension, and coronary artery disease, received several psychotropic medications for anxiety and depression. The medical record showed multiple medication changes, including new orders for Buspar, Ativan, and Hydroxyzine, but there was no documentation of any risk and benefit discussion or signed acknowledgment by the resident or representative. The MDS Coordinator and DON both confirmed that the facility did not have a process for reviewing or documenting the risks and benefits of psychotropic medications with residents or their representatives. Another resident, with diagnoses including Alzheimer's disease, insomnia, nightmare disorder, depression, unspecified dementia with agitation, and convulsions, was prescribed multiple high-risk medications such as antipsychotics, antidepressants, anticonvulsants, and diuretics. The care plan included non-pharmacological interventions and monitoring for side effects, but there was no available documentation of risk versus benefit information being provided to the resident or representative. The DON confirmed that the facility had never reviewed or documented such information with residents or their representatives.