Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
A deficiency was identified when the facility failed to obtain informed consent for psychotropic medications for one resident. The resident, who had diagnoses including bipolar disorder, depression, anxiety disorder, and dementia, was prescribed Sertraline, Quetiapine, and Buspirone for depression, bipolar disorder, and anxiety, respectively. Physician's orders and care plans documented the use of these medications for the resident's mental health conditions, but the clinical record did not contain psychotropic consent forms indicating that the resident or their representative had been informed of, and accepted, the medications, including their risks and benefits. During an interview, the DON confirmed that the resident was receiving these psychotropic medications daily without a completed consent form. Facility policy required that consent be obtained and documented for the use of psychotropic medications, including information about the intended benefits and potential risks, as well as confirmation of understanding from the resident or representative. The absence of these consent forms constituted a failure to ensure the resident was fully informed and had agreed to the treatment as required by facility policy and resident rights.