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F0552
D

Failure to Obtain Informed Consent for Psychotropic Medication

Santa Clara, New Mexico Survey Completed on 07-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident and/or their representative was informed in advance about the administration of Lorazepam, including the reasons, risks, and benefits of the medication. Record review showed that the resident was admitted to the facility and had a physician's order for Lorazepam to be administered on specific days for anxiety and agitation. However, the medical record did not contain documentation of consent for the resident to take Lorazepam. During an interview, the DON confirmed that there was no written consent in the resident's file and acknowledged that staff are expected to obtain such consent prior to starting any psychotropic medication.

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