Failure to Provide Education and Refusal Opportunity for Psychoactive Medications
Penalty
Summary
Facility staff failed to provide required education and the opportunity to refuse psychoactive medications for one resident. Clinical record review showed that the resident was prescribed Risperidone 0.5 mg daily and Sertraline 50 mg daily, and these medications were administered as ordered. However, there was no documentation in the medical record indicating that the resident or their representative was informed about the risks and benefits of these medications, nor was there evidence that the resident was given the option to refuse them. Interviews with facility staff, including the director of nursing, confirmed that the facility's policy requires obtaining consent and providing education regarding psychotropic medications, which carry specialized risks for side effects. The facility's own policy also states that residents have the right to accept or decline such medications after being informed of the risks, benefits, and alternatives. Despite these requirements, no documentation or evidence of such education or opportunity for refusal was found for the resident in question.