Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent prior to the administration of psychoactive medications, as required by both facility policy and state regulations. In one instance, a resident with severe cognitive impairment and a history of dementia and traumatic brain injury was prescribed and administered Haldol, an antipsychotic medication, for agitation without obtaining prior consent from the resident's representative. Documentation showed that the medication was administered before the consent form was signed, and the care plan was updated to reflect antipsychotic use only after the medication had already been given. Interviews with staff confirmed that consent should have been obtained before administration, but this process was not followed in this case. In another case, a resident with Alzheimer's disease and unspecified dementia was prescribed multiple psychoactive medications, including Zyprexa, Buspirone, Lorazepam, and Risperidone. Review of medical records revealed that these medications were administered before the required informed consent forms were signed and dated by the resident's guardian or responsible party. In some instances, consent forms were missing entirely or were not properly completed. Staff interviews confirmed that the process for obtaining and documenting consent was not consistently followed, and the DON acknowledged that medications had been administered prior to receiving the necessary consents. Facility policy requires that residents and their representatives be informed of the risks, benefits, and alternatives to psychoactive medications before initiation or dose increases, and that consent be documented in advance. However, record reviews and staff interviews demonstrated that these procedures were not adhered to for the residents in question. The lack of proper consent and documentation could affect the residents' right to self-determination and informed participation in their care.