Failure to Obtain Written Consent for Psychotropic Medications
Penalty
Summary
A review of facility records and staff interviews revealed that the facility failed to obtain written consent for psychotropic medications for one resident. The resident, who was rarely able to understand or be understood according to the most recent Minimum Data Set (MDS) assessment, was prescribed Depakote for a mood disorder and Ativan for an anxiety disorder. The medical record did not contain any documentation of consent for these medications, nor evidence that the resident's representative was informed of the risks and benefits associated with their use. During a joint record review and interview, the Assistant Director of Nursing (ADON) confirmed the absence of the required consents and lack of communication with the resident's representative.