Failure to Implement Psychiatric Medication Recommendation Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when the facility failed to implement a psychiatric recommendation for a resident with dementia and major depressive disorder. The psychiatric provider recommended an increase in sertraline to 50 mg daily due to inappropriate behaviors, and this recommendation was approved by the resident's provider. However, the facility placed the new order on hold pending consent from the resident's Power of Attorney (POA). Documentation shows that a call was made to the POA to obtain consent, and a message was left, but there was no further evidence of additional attempts to contact the POA or obtain consent after that date. Interviews with staff confirmed that the facility's process requires obtaining and documenting consent from the resident representative before implementing changes to psychotropic medications. The LPN and DON both indicated that documentation of attempts to obtain consent should be present in the progress notes, but no such documentation was found after the initial attempt. The resident's provider was unaware that the medication increase had not been implemented and believed the resident was already receiving the higher dose.