Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication prior to starting the medication regimen for one resident diagnosed with depression. According to the facility's policy, informed consent, which includes a discussion of the medication's risks and benefits, must be obtained from the resident or their representative before initiating psychotropic drugs such as antidepressants. Record review showed that the resident was prescribed and began receiving an antidepressant medication, but the informed consent form was not completed until several months after the medication was started. Interviews with facility staff, including a Charge RN and the Director of Nursing, confirmed that the expectation was for informed consent to be obtained and documented in the resident's electronic health record prior to the first dose of the medication. However, staff were unable to locate an informed consent form dated before the start of the antidepressant, and acknowledged that the required consent was not obtained prior to administration. This failure was identified through both record review and staff interviews.