Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for one resident with severe late onset Alzheimer's dementia, agitation, insomnia, and depression. Review of the resident's care plans showed no focus or interventions related to the use of psychotropic medications or monitoring for adverse consequences. Multiple orders for Lorazepam were present in the resident's record, but there was no documented consent for these medications, either written or verbal. The resident's family member and Durable Power of Attorney (DPOA) was not aware that the resident was receiving Lorazepam and reported not having given permission for its use. Interviews with facility staff revealed that the process for obtaining and documenting consent was inconsistent and lacked a standard procedure. The social worker was unable to locate any notes indicating that consent had been obtained for the prescribed Lorazepam, and the nurse liaison confirmed there was no documentation of verbal consent in the resident's record. The absence of proper documentation and communication resulted in the resident or their representative not being fully informed or able to make decisions regarding the risks, benefits, and alternatives to the prescribed psychotropic medication.