Failure to Obtain Informed Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent prior to the administration of psychotropic medications for one of five sampled residents. Specifically, a resident with diagnoses including depression and dementia, and who was assessed as severely cognitively impaired, was started on Sertraline without documented consent from the resident's representative until 18 days after the medication was initiated. Additionally, while consent for Bupropion was obtained on the day it was started, it was signed by the resident despite their low cognitive status, and there was no documentation that the representative was notified or provided consent for subsequent dose reductions of Bupropion. Staff interviews confirmed that the expectation was for consent to be obtained from the resident or their power of attorney prior to starting psychotropic medications, and that any dosage changes should be communicated and documented with the resident or representative. However, documentation in the electronic health record did not show that these procedures were followed for the resident in question, particularly given the resident's cognitive impairment and the need for representative involvement in consent decisions.