Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medications, as required by facility policy. For one resident with severe cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), multiple psychotropic medications were prescribed, including lorazepam, duloxetine, trazodone, and quetiapine. The medical record showed that only verbal consent was obtained, with incomplete and undated written consent forms lacking initials and signatures from the POAHC, and no documentation of attempts to obtain proper written consent. Another resident with moderate cognitive impairment and an activated POAHC was prescribed venlafaxine and bupropion. The consent forms for these medications were incomplete, missing essential information such as the method of administration, reasons for the medication, alternative treatments, probable consequences of not receiving the medication, and staff signatures. For a third resident with intact cognition, the consent form for citalopram was also incomplete, lacking information on alternative treatments and the consequences of not receiving the medication. Interviews with facility staff confirmed that the protocol requires the social worker to obtain written consent from the resident or POA, with a written signature to be obtained within 10 days if verbal consent is initially given. However, the documentation reviewed did not meet these requirements, as written consents were either missing, incomplete, or not properly signed and dated, leading to the deficiency.