Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for one resident. According to the facility's policy and procedure on psychotherapeutic drug treatment, informed consent must be obtained from the resident or their representative prior to the use of such medications, including providing information about the need for the medication, its desired effects, and potential side effects. The resident in question was determined to lack capacity to make decisions, and a physician's order was given to administer Ativan for anxiety. However, a review of the resident's medical record did not show any documented evidence that informed consent was obtained for the use of Ativan as ordered. Interviews with facility staff, including an RN and the DON, confirmed that a new informed consent was not obtained when the Ativan medication was ordered. The Ativan prescription was not renewed after an initial 14-day period, and when it was reordered, the required informed consent process was not completed. This failure was acknowledged and verified by the DON during the survey.