Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Fine: $25,116
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 informed consent for the use of divalproex sodium, an anticonvulsant medication used as an antipsychotic, for a resident admitted with dementia with behavioral disturbances and convulsions. Documentation showed that while verbal consent was obtained for other psychotropic medications, divalproex sodium was not included. The resident's admission assessment indicated the use of psychotropic medications to manage agitation and aggressive behaviors, and subsequent interdisciplinary team review confirmed the administration of divalproex sodium. However, a review of the clinical record revealed no signed consent for this medication, and facility staff acknowledged that the required consent was not obtained.