Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to document that a resident was informed in advance of the risks and benefits associated with the use of Chlordiazepoxide HCl, a psychotropic medication prescribed for alcohol withdrawal. The resident, who had diagnoses including anxiety, depression, and alcohol dependence, was cognitively intact and had a history of leaving the facility to consume alcohol. Following an incident where the resident left to drink alcohol, the Medical Director, along with the DON and a family member via phone, discussed a treatment plan involving Chlordiazepoxide HCl. The medication was ordered in a tapered dose over five days, and monitoring for alcohol withdrawal symptoms was implemented per physician's orders. Despite evidence of verbal education and discussion about the medication's side effects and treatment plan, there was no written consent form for Chlordiazepoxide HCl in the resident's electronic medical record. Consent forms for other psychotropic medications were present and signed, but not for Chlordiazepoxide HCl. Interviews with the resident, Medical Director, DON, and Administrator confirmed that the resident did not sign any documentation agreeing to the treatment, and the resident did not recall consenting to the medication. This lack of documented informed consent constituted the deficiency identified during the survey.