Failure to Obtain Informed Consent Prior to Administering Psychotropic Medications
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and an activated Power of Attorney for Healthcare (POAHC) was administered multiple psychotropic medications without obtaining informed consent prior to the start of the medications. The facility's policy required that informed consent forms be completed and education provided to the resident or their representative before administering such medications. However, the resident's medical record showed that Seroquel, melatonin, and BuSpar were started before the consent forms were signed, and there was no documentation that verbal consent was obtained prior to administration. Additionally, citalopram was started before the consent form was signed, and lorazepam was administered without any informed consent form on file. The resident in question had diagnoses including encephalopathy, nervous system degeneration due to alcohol, alcohol dependence, a history of stroke, and anxiety disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The Director of Nursing confirmed during interview that informed consent should have been obtained prior to starting these medications, but this process was not followed as required by facility policy.