Failure to Obtain Consent Prior to Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consent prior to the administration of psychotropic medications. For one resident with a diagnosis of depression who was cognitively intact, Sertraline was ordered and administered before the consent form was signed, with staff acknowledging that consent should have been obtained at the time the order was placed. The Director of Nursing Service confirmed that the expectation was for consent to be obtained before medication administration. In another case, a resident who was severely cognitively impaired and had a court-appointed guardian received psychotropic medications, including Mirtazapine and Risperidone, before the guardian was notified and consent was obtained. The guardian reported not being alerted to the resident's arrival and did not receive the consent forms until after the medications had already been administered. Staff interviews confirmed that consents should have been obtained prior to the first dose, but this did not occur.