Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident received informed consent prior to the administration of a psychotropic medication, specifically Remeron (Mirtazapine), which is an antidepressant. The resident, who had diagnoses including dementia, stroke, and high blood pressure, was his own responsible party but was rarely able to understand or be understood by others, and had severe daily decision-making impairment. Despite this, the resident was administered Remeron on two occasions without a signed psychotropic consent form present in his chart. The care plan indicated that staff were to educate the resident or family about the risks, benefits, and side effects of the medication, but this was not documented as having occurred. Interviews with facility staff, including the charge nurse, ADON, DON, and Administrator, confirmed that the required consent was not obtained prior to medication administration. The charge nurse admitted to forgetting to complete the consent form, and both the ADON and DON acknowledged that obtaining consent was their responsibility and should have occurred before the medication was given. The facility's policy also required that no psychotropic medication be administered without informed consent unless in an emergency, which was not the case in this situation.