Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by multiple deficiencies in the administration, monitoring, and documentation of such medications for three residents. For one resident with a history of hemiplegia, hemiparesis, depression, and anxiety, the facility did not obtain informed consent prior to administering certain psychotropic medications, specifically diazepam and duloxetine. The resident reported not being informed about the medications being administered, and staff interviews confirmed that the required consent process was not followed, contrary to facility policy and procedure. Additionally, the facility did not provide ongoing re-evaluation of the need for psychotropic medications for this resident, as there was no documented monitoring for measurable behaviors or adverse effects related to bupropion, diazepam, or duloxetine. Orders for PRN diazepam lacked specific, measurable behavioral manifestations and did not include an end date, both of which are required by facility policy to ensure appropriate use and regular reassessment of high-risk medications. Staff interviews confirmed that these omissions could result in the administration of unnecessary medications and potential harm to the resident. For another resident with dementia and anxiety disorder, the facility failed to monitor for measurable behaviors and adverse effects of Risperdal for a specified period and did not complete required behavior summary side effect documentation for several months for both Risperdal and Klonopin. The lack of behavior monitoring and documentation was acknowledged by staff, who stated that such monitoring is necessary to evaluate medication effectiveness and to support gradual dose reduction. These failures were in direct violation of the facility's policies regarding psychotropic medication use, monitoring, and resident rights.