Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of a psychotropic medication. Specifically, for a female resident with diagnoses including Type 2 Diabetes Mellitus, Paranoid Schizophrenia, and Celiac Disease, there was no documented informed consent for the use of Olanzapine, an antipsychotic medication, in the resident's medical record. The resident had severe cognitive impairment as indicated by a BIMS score of 6, and her care plan included the use of antipsychotic medication with related interventions. Despite an order for Olanzapine and ongoing care, the required consent form was not present in the electronic medical record, and staff were noted to be awaiting the consent form from the contracted psychiatry agency. Interviews with facility staff revealed a lack of clear responsibility for obtaining psychotropic medication consents, with both nursing staff and the social worker sometimes involved. The DON and Administrator both acknowledged the importance of obtaining consent quickly, but there was no specific staff member assigned to this task. The facility's policy states that residents have the right to receive information about psychoactive medications and to refuse consent, but this process was not followed for the resident in question, as evidenced by the missing consent documentation for Olanzapine.