Failure to Obtain Informed Consent for Mood-Altering Medications
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to obtain signed informed consent prior to administering mood-altering medications to a resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, anxiety, and depression, was able to communicate their needs. Review of the electronic health record (EHR) and medication administration record (MAR) showed that the resident was prescribed and received Buspirone and Duloxetine, both mood-altering medications, without any documented consents for their use. During interviews, both the Resident Care Manager/LPN and the Director of Nursing Services confirmed that the required consents were not present in the EHR and acknowledged that this did not meet facility expectations.