Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the initiation of psychotropic medications for two residents with significant cognitive impairments and psychiatric diagnoses. For one resident with dementia, anxiety, and depressive disorder, Depakote was started for generalized anxiety without any documentation that the resident's representative was informed in advance of the risks or benefits. The Medication Administration Record confirmed the medication was administered as ordered, and interviews with the DON and Psychiatric Nurse Practitioner revealed that no formal consent process was in place, and there was uncertainty about who was responsible for obtaining consent. Similarly, another resident with schizophrenia, traumatic brain injury, and depressive disorder was started on lorazepam for anxiety without evidence that the responsible party was informed of the risks and benefits prior to administration. The resident's medical record lacked documentation of this required communication, and staff interviews confirmed that the facility did not have a consent form or consistent process for obtaining consent for psychotropic medications. Both the DON and Nurse Practitioners acknowledged the expectation for consent but indicated it was not being consistently obtained or documented.