Failure to Inform Residents or Representatives of Antipsychotic Medication Risks and Alternatives
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about the risks, benefits, and alternative treatments associated with the use of antipsychotic medications for two residents. For one resident with severe cognitive impairment and a diagnosis of dementia, Seroquel was administered daily from admission, and documentation showed the resident experienced excessive sleepiness, prompting a physician to note probable overmedication. Despite ongoing administration and monitoring for side effects, there was no documentation in either the electronic or paper medical records that the resident or their family had been educated about the antipsychotic medication. Another resident with diagnoses including unspecified dementia with behavioral disturbance, bipolar disorder, anxiety disorder, and a history of alcohol abuse was also prescribed multiple psychotropic medications, including Seroquel. The care plan and medication records confirmed regular administration of these medications and ongoing behavioral monitoring. However, there was no documentation that the resident or their family had been informed of the risks, benefits, or alternative treatments for the antipsychotic medication. Interviews with facility staff, including the Director of Nursing Services and the Minimum Data Set Coordinator, confirmed the absence of documentation regarding resident or family education on antipsychotic medication use for both residents. The lack of documented education and informed consent for antipsychotic medication use constituted the deficiency identified during the survey.