Failure to Obtain Informed Consent for Psychotropic Medication Dose Increase
Penalty
Summary
The facility failed to obtain informed consent prior to increasing the dosage of Seroquel, an antipsychotic medication, for a resident with diagnoses including blindness, hypothyroidism, arthritis, depression, visual hallucinations, and anxiety. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, and had regular virtual appointments with a private psychiatrist, which were arranged by the Social Services Director and attended by the resident's family. The resident's Medication Administration Record showed an increase in Seroquel dosage from 25 mg in the morning and 50 mg at night to 50 mg twice daily, as recommended by the psychiatrist. Despite this change, the last documented informed consent for Seroquel was obtained prior to the dosage increase, and there was no documentation of informed consent for the new, higher dose. The Director of Nursing confirmed that no informed consent was obtained for the increased dosage, and the Registered Pharmacist stated that informed consent is required before increasing a medication dose. Facility policy also indicated that psychotropic medication management is an interdisciplinary process involving the resident and their representative.