Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the use of psychotropic medications prior to administration for three residents. For one resident with schizophrenia, anxiety, and major depression, record reviews showed that antipsychotic medications were started upon admission, but there was no psychotropic medication informed consent form present in the medical record at the time of survey. When a consent form was later provided, it was incomplete, missing key information such as the resident's current medications and physician details. Further investigation revealed inconsistencies in the documentation, including a consent form with signatures that did not match the original, and no evidence that the resident's guardian had been properly informed or contacted regarding the consent. Another resident with hemiplegia, diabetes, dementia, and a history of stroke was found to be receiving antidepressant and antipsychotic medications on a routine basis. The medical record lacked documentation that the resident or their responsible party had been informed of the benefits, risks, and alternatives to these medications. Interviews with facility staff confirmed that such documentation was expected but not present in the resident's health record. A third resident with hydrocephalus, diabetes, and dementia, who was cognitively intact, was also receiving routine antidepressant medications. Similar to the other cases, there was no documentation in the medical record indicating that informed consent had been obtained or that the resident or their representative had been informed about the medications. Staff interviews confirmed the absence of required documentation for informed consent prior to the administration of psychotropic medications.