Failure to Obtain Updated Consent for Antipsychotic Medication Change
Penalty
Summary
The facility failed to inform a resident or her responsible party in advance about a change in her antipsychotic medication dosage, specifically the reduction of risperidone from 0.75 mg to 0.5 mg. The resident, an elderly female with severe cognitive impairment and multiple psychiatric diagnoses including major depressive disorder, severe unspecified dementia with behavioral disturbance, generalized anxiety disorder, and psychotic disorder with delusions, had a signed consent form on file for the original dosage. However, when the dosage was reduced, no updated consent form or documentation was obtained to reflect this change. During an interview, the MDS Coordinator acknowledged not being aware that a new consent form was required for the dosage adjustment, resulting in the absence of proper documentation. The facility's policy requires that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications prior to any initiation or change, and that this communication be documented in the medical record. This policy was not followed in this instance, as evidenced by the lack of updated consent for the medication change.