Failure to Obtain and Maintain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and maintain valid informed consent for the administration of psychotropic medications for two of three sampled residents. For one resident with dementia and bipolar disorder, the most recent informed consent for psychotropic medication was dated nearly a year prior, despite facility policy requiring renewal every six months. This resident was determined to be incapable of making healthcare decisions, yet new psychotropic medications were initiated without updated consent documentation. The Director of Nursing confirmed that consents should be current and acknowledged the lapse. For another resident with major depressive disorder and anxiety disorder, informed consent forms for prescribed psychotropic medications were found to be incomplete and invalid, lacking required dates and physician signatures. The responsible RN confirmed the deficiencies in the consent documentation. Facility policy specifies that informed consent must be obtained by the healthcare provider prior to the first dose and renewed every six months, but this was not followed in these cases.