Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain and document consent from a resident's Responsible Party (RP) for the use of psychotropic medications. The resident was admitted with diagnoses including dementia with behavioral disturbance, depression, and a history of stroke. Physician orders were in place for mirtazapine and quetiapine fumarate to be administered for depression and behavioral disturbances, respectively. The resident was assessed as severely cognitively impaired and had received both an antidepressant and an antipsychotic during the review period. A review of the resident's medical records revealed no documentation of consent, discussion of risks versus benefits, or alternative treatment options with the RP regarding the use of psychotropic medications. Interviews with facility staff, including the DON, Unit Manager, and Administrator, confirmed that consent should have been obtained at admission but was missed. Staff indicated that obtaining consent is the responsibility of the admitting nurse, unit manager, and all licensed nurses entering the orders, and the omission was attributed to the timing of the admission.