Failure to Obtain and Renew Informed Consent for Psychotropic Medications and Bedrails
Penalty
Summary
The facility failed to properly obtain and renew informed consent for the use of psychotropic medications and bedrails for several residents, as required by law and facility policy. For three residents receiving psychotropic medications, the facility either did not obtain the initial informed consent or failed to renew the consent every six months as mandated. Specifically, one resident did not have current consents for multiple psychotropic medications, with the last consents obtained more than six months prior. Another resident was administered antipsychotic medications without the required renewal of informed consent after six months. A third resident was given psychotropic medications without any documented informed consent in the medical record. Additionally, the facility failed to obtain the correct informed consent for the use of bedrails for another resident. The consent on file was for bilateral half side rails, while the resident was observed using bilateral quarter side rails, and there was no documentation of consent for the specific type of bedrail in use. Interviews with nursing staff and the DON confirmed these findings and acknowledged that the required consents were either missing or not current at the time the medications and bedrails were in use. The deficiencies were identified through interviews, medical record reviews, and policy and procedure reviews. The facility's own policies require that informed consent be obtained and documented for the use of psychotropic medications and physical restraints, including bedrails, and that these consents be renewed every six months. The lack of current and appropriate consents was verified by both nursing staff and the DON during the survey process.