Failure to Obtain 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. Specifically, a resident with severe cognitive impairment and multiple mental health diagnoses, including bipolar disorder and depression, was prescribed and administered quetiapine and duloxetine. Documentation in the Electronic Health Record did not show any evidence of consent from the resident or their representative for either medication. Staff interviews confirmed that a consent form should have been completed when the psychotropic medications were prescribed or if the dosage was changed. Both the Administrator and the DON acknowledged that they could not locate the required consent documentation for the medications in question, indicating that the necessary process for obtaining and recording consent was not followed.