Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, delirium, and other medical conditions was administered psychotropic medication (Trazodone) without obtaining informed, signed consent from the resident's representative, who held power of attorney. The resident's daughter, who was actively involved in his care, reported that she had not consented to the use of Trazodone and expressed concerns about the resident's lethargy after receiving both Melatonin and Trazodone for sleep. Facility staff confirmed that there was no psychotropic consent on file for this resident and acknowledged the requirement to inform the resident or representative of the medication's risks and obtain signed consent prior to administration. Review of the Medication Administration Record showed that both Melatonin and Trazodone were administered to the resident on a specific date, and physician orders for these medications were in place for a defined period. The facility's policy requires compliance with CMS regulations regarding psychotropic medication use, including informing the resident or representative about the medication's initiation, purpose, and risks. Despite these requirements, the facility failed to secure the necessary informed consent before administering the psychotropic medication.