Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of psychotropic medications for one resident. Review of the facility's policy indicated that residents, families, or resident representatives must be informed of the benefits, risks, and alternatives to psychotropic medications, including any black box warnings, prior to starting or increasing such medications. For the resident in question, medical records showed active orders and administration of multiple psychotropic medications, including alprazolam, buspirone, sertraline, and trazodone, for conditions such as anxiety and depression. Despite the resident being cognitively intact, as evidenced by a BIMS score of 14, there was no documentation of informed consent for the use of these medications in the resident's medical record. The care plan and medication administration records confirmed ongoing use of these medications, and the DON verified that no psychotropic consent form was present for the resident as required by facility policy and regulation.