Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident's right to be informed in advance of the risks and benefits of proposed care, treatment alternatives, and to choose preferred options was upheld. Specifically, for one resident with a history of psychotic disorder, major depressive disorder, and anxiety disorder, there were no signed and dated consents from the resident's Power of Attorney (POA) for the use of multiple psychoactive medications, including Seroquel, Buspar, Zoloft, Trazodone, and Depakote. Record review showed that the resident had moderate cognitive impairment and was prescribed these medications for her mental health conditions. The resident was not aware of the medications she was taking, and the electronic health record did not contain any consents for these psychoactive medications. During interviews, the DON confirmed that no consents were found in the electronic or hard copy records, except for an unsigned and undated consent for Seroquel. The DON acknowledged responsibility for ensuring medication consents were obtained prior to administration and was unable to explain why the consents were missing. Additionally, the facility's policy on antipsychotic medication use did not include information regarding the need to obtain consent for psychoactive medications.