Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for multiple residents. For one resident with diagnoses including acute respiratory failure, PTSD, schizoaffective disorder, and low back pain, there was no signed consent for Depakote Sprinkles, despite the medication being administered as ordered. The resident had moderately impaired cognition and was receiving several psychotropic medications, but neither the electronic nor paper medical records contained the required consent documentation. Another resident with unspecified dementia, depression, anxiety disorder, and psychosis, and who had severely impaired cognition, was administered Seroquel without a signed consent. The medication was given as ordered except for a few refusals, but no documentation of informed consent was found in the records. Similarly, a third resident with anxiety disorder, dementia, and mood disorder, and who also had severely impaired cognition, was administered Sertraline and Seroquel without any signed consents present in the medical records. A fourth resident, who was cognitively intact and had diagnoses including psychotic disorder with delusions, hemiplegia, and hemiparesis, was administered Duloxetine, Depakote, Xanax, and Risperdal without signed consents. The care plans for these residents included interventions to educate about risks, benefits, and side effects, but the required consents were not obtained or documented. Interviews with nursing staff and the DON confirmed that the process for obtaining and filing consents was not consistently followed, and that the lack of consents could result in residents receiving medications that they or their families did not want.