Failure to Obtain Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to review the risks and benefits of a newly prescribed psychotropic medication with the legal representative of a resident who had a legal guardian. The resident, who had a history of intracranial hemorrhage, cerebral infarction, hemiplegia, hemiparesis, bipolar disorder, depression, and anxiety, was started on Risperidone without documented consent or evidence that the guardian was informed of the medication's risks and benefits. The guardian reported not being notified of the new medication order and did not provide consent for its use. During a care conference, the guardian requested discontinuation of the medication, but it was not stopped until eleven days later. Record review confirmed that there was no documentation of the guardian being notified or consenting to the use of Risperidone. Staff interviews revealed that the facility's expectation was to obtain consent from the resident's legal representative prior to administering psychotropic medications, but this process was not followed in this case. The Director of Nursing acknowledged that the required consent form was not signed by the guardian and that the medication was not discontinued promptly after the guardian's request.