Failure to Obtain Required Consent for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed and able to participate in her treatment regarding the administration of an antipsychotic medication. Specifically, a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia and psychosis, was administered Haldol by an LVN without evidence of the required state consent form (Form 3713) in her medical record. The resident's care plan included interventions for medication refusal and behavioral issues, and her responsible party (RP) reported providing both written and verbal consent for the medication. However, the facility did not have the necessary documentation of consent on file at the time of administration. The Director of Nursing (DON) confirmed that the consent form had not been completed for the antipsychotic medication and acknowledged the oversight. The facility's policy required proper documentation and initialing of the medication administration record (MAR), but the absence of the signed consent form indicated a lapse in ensuring the resident's right to be informed and to participate in her care and treatment decisions.