Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and provide advance information regarding the risks and benefits of psychotropic medications prior to initiating treatment for a resident with chronic obstructive pulmonary disease, bipolar disorder, and depressive disorder. The resident was started on clonazepam for anxiety and venlafaxine for depression, as documented in physician orders and progress notes. However, a review of the medical record revealed no documentation that the resident was informed about the risks and benefits of these medications or that consent was obtained prior to administration. The Medication Administration Record confirmed that both medications were administered as ordered. Interviews with facility staff, including the Nurse Practitioner, Psychiatric Nurse Practitioner, and Director of Nursing, revealed inconsistent practices regarding the process for obtaining informed consent for psychotropic medications. The Psychiatric Nurse Practitioner indicated that discussions with the resident focused on symptoms rather than explicitly covering risks, benefits, or obtaining formal consent. The Director of Nursing acknowledged that consents were not consistently obtained, and the Administrator recognized the need for improvement in this area. The resident involved was cognitively intact and reported well-controlled anxiety and depression at the time of the survey.