Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks, benefits, and treatment alternatives associated with the use of psychotropic medications prior to administration. Specifically, two residents with cognitive impairments and diagnoses including Alzheimer's dementia, depression, and anxiety were administered Ativan (lorazepam), an antianxiety and antipsychotic medication, without documented evidence of informed consent. For one resident, physician orders indicated the use of transdermal Ativan gel as needed for agitation, and the medication was administered multiple times over several months. However, there was no documentation that the resident's representative was informed or provided consent prior to the initiation of this medication. Similarly, another resident with cognitive impairment and diagnoses of Alzheimer's dementia and anxiety received both oral and transdermal Ativan for anxiety and agitation, as ordered by the physician. The medication administration records confirmed multiple doses were given, but again, there was no evidence in the clinical record that informed consent was obtained from the resident's representative before starting the medication. An interview with the DON confirmed that the facility was only obtaining informed consent for antipsychotic medications, not for other psychotropic medications.