Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for two residents who were reviewed for unnecessary medication use. For one resident with diagnoses including depression, anxiety, and insomnia, there was no documentation that the resident or their representative was informed about the initiation of an antipsychotic medication, nor was there a signed consent for its use. Similarly, another resident with chronic PTSD, bipolar disorder, and depression was started on two antidepressant medications without any record of informed consent or documentation that the resident or their representative had been informed about the medications. Interviews with facility staff revealed that admission nurses were responsible for obtaining consents at admission, or floor nurses if a new order was received. The Director of Nursing Services acknowledged that the consents for the psychotropic medications were not signed for these two residents at the time of admission, attributing the omission to an oversight by the admitting nurses.