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F0552
D

Failure to Obtain Informed Consent for Psychotropic Medication

Martinsburg, West Virginia Survey Completed on 06-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a diagnosis of depressive disorder, who lacked capacity to make medical decisions, was prescribed Sertraline HCI 50 mg. The facility did not provide the resident's medical representative with information regarding the risks and benefits of the medication, nor were alternative treatment options discussed. During the survey, the Director of Nursing (DON) was unable to produce an informed consent form for the medication. Although there was documentation of an attempt to contact the resident's representative, there was no evidence that the representative was informed or that consent was obtained prior to administering the medication.

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