Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of a psychotropic medication, Duloxetine, prior to its administration to a resident diagnosed with depression. The resident was cognitively intact and able to verbalize needs. The care plan required staff to educate the resident about the risks and benefits of antidepressant medication and to monitor for adverse reactions. Despite this, review of the resident’s medical record and medication administration records showed that Duloxetine was administered 55 times over a two-month period without documented consent. Interviews with facility staff, including a registered nurse, resident care manager, and director of nursing, confirmed that consent for psychotropic medications was required prior to administration. Staff were unable to locate documentation of consent for Duloxetine prior to its use, and acknowledged that the consent was not obtained until after the medication had already been administered multiple times. This failure was identified during interviews and record reviews, and was in violation of state regulations requiring informed consent for psychotropic medication use.