Failure to Obtain Timely Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's legal guardian was informed of the risks and benefits of a prescribed psychotropic medication, lorazepam, as required by facility policy and state regulations. The resident, who had intact cognition and diagnoses including schizophrenia, generalized anxiety disorder, major depressive disorder, and mood affective disorder, had a legal guardian appointed. Lorazepam was ordered for the resident, but there was no documentation of informed consent from the guardian at the time the medication was prescribed. Staff interviews and record reviews revealed that the facility's process for obtaining informed consent was not followed. The Director of Nursing stated that informed consent is usually obtained when psychotropic medications are ordered, and that medications are not administered without signed consent. However, the social worker confirmed that consent was not obtained until after the surveyor's request, and there was no documentation of verbal consent or attempts to contact the guardian prior to the survey. The resident had not received lorazepam before the consent was obtained, but the required documentation and process were not completed in a timely manner.