Failure to Obtain and Document Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident with a legal guardian was fully informed and provided with proper consent for the use of multiple psychoactive medications, including antipsychotics and antidepressants. Record reviews showed that consent forms for medications such as Zyprexa, Haldol, Perseris, Zoloft, and Trazodone were either missing the legal guardian's dated signature or lacked documentation of when telephone consent was obtained. The facility's care plan included interventions to educate the resident, family, or caregivers about the risks, benefits, and side effects of these medications, but documentation did not confirm that this education and informed consent process was properly completed. During interviews, the ADON acknowledged that she had failed to date her signature and the legal guardian's telephone consent on the relevant forms, attributing this to oversight. The resident in question had diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, and was assessed as having intact cognition. Despite this, the resident was unable to answer questions about his medications during an interview. Facility policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications prior to initiation or dose changes, and that this be documented, but this process was not followed as required.