Missing Psychotropic Medication Consent Forms in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents who were prescribed and received antipsychotic medications. For one resident with schizophrenia and severe cognitive impairment, there was no evidence in the medical record of the required state psychotropic medication consent form, despite the resident receiving risperidone as prescribed. Similarly, another resident with bipolar disorder and no cognitive impairment received aripiprazole for depression, but the required consent form was also missing from her medical record. In both cases, the medication administration records confirmed that the medications were administered as ordered by the physician, but the necessary documentation was not present in the residents' files. Interviews with the DON and Administrator confirmed that the required consent forms were not included in the medical records at the time of review. The DON acknowledged that the consents existed but had not yet been scanned into the electronic medical records, as the responsibility for scanning had not been assigned to a specific staff member and had defaulted to the DON. Both the DON and Administrator agreed that all residents prescribed antipsychotic medications should have the appropriate consent forms documented in their medical records, and the absence of these forms was confirmed during the survey.