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F0552
D

Failure to Obtain Consent for Psychotropic Medication

Mount Airy, North Carolina Survey Completed on 06-11-2025

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 obtain consent and inform a resident or their representative in advance about the risks and benefits of initiating a psychotropic medication, specifically Lorazepam, for anxiety. The resident in question was admitted with diagnoses including generalized anxiety disorder and depression, and was assessed as severely cognitively impaired with no behavioral symptoms. Despite the initiation of Lorazepam as needed for anxiety, the medical record did not contain documentation that the resident's representative was informed or provided consent prior to starting the medication. During an interview, the DON confirmed that consents were only being obtained for antipsychotic medications, not for all psychotropic medications, due to the limitations of the facility's existing consent forms.

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