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F0552
E

Failure to Obtain Informed Consent Prior to Antipsychotic Medication Administration

Arlington, Texas Survey Completed on 07-03-2025

Penalty

Fine: $342,800
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of antipsychotic medications. Record review showed that the resident, who had moderate cognitive impairment and diagnoses including depression and Alzheimer's Disease, began receiving Olanzapine and Aripiprazole as ordered by the physician. However, the consent forms for these medications were not signed by the responsible party until several weeks after the medications had already been administered. There was no documentation of verbal consent being obtained prior to the administration of the first doses. Interviews with facility staff revealed that the ADONs were responsible for obtaining consents before administering antipsychotic medications, and that the process sometimes involved obtaining verbal consent over the phone, which should be documented with the date. The responsible party for the resident did not recall giving consent or discussing the medications over the phone. Additionally, the facility administrator was unable to provide a policy regarding consents for antipsychotic medications at the time of the survey.

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