Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents or their legal representatives were fully informed and provided written consent prior to the administration of psychotropic medications. For one resident with intact cognition and a diagnosis of anxiety and muscle spasms, there was no documented consent for the prescribed diazepam, a medication with a black box warning. For another resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), consent forms for lorazepam, bupropion, and duloxetine were not properly initialed, dated, or signed by the POAHC after the expiration of verbal consent. A third resident, who had severe cognitive impairment and an activated POAHC, was prescribed olanzapine, also with a black box warning, without a completed informed consent form in the medical record. The facility's policy required that residents or their responsible parties be informed of the reasons for psychotropic medication orders, possible side effects, and alternative methods, and that written consent be obtained and documented. Staff interviews confirmed that the required consent forms were either missing, incomplete, or not properly reviewed and signed, resulting in a lack of documented informed consent for the use of psychotropic medications for these residents.