Failure to Obtain Informed Consent for Psychotropic Medication Change
Penalty
Summary
The facility failed to obtain informed consent and adequately inform the resident's responsible party (RP) about the risks and benefits of a psychotropic medication prior to increasing its frequency for a resident with dementia and anxiety disorder. The resident, who had severely impaired cognitive skills and exhibited behavioral symptoms, was receiving antipsychotic and antianxiety medications, including ABH gel. The physician order for ABH gel was changed from twice daily to three times daily, but there was no documented evidence that the RP was informed of this change or provided with information about the medication's risks and benefits before the change was implemented. Interviews with the RP revealed she was unaware of what ABH gel was, had not been informed about the medication or its increased frequency, and had not discussed its risks and benefits with staff. The unit manager acknowledged completing a consent form after a care conference but did not recall discussing the risks and benefits or the frequency increase with the RP at the time of the order change. The DON confirmed that the facility's process required obtaining consent prior to starting or changing psychotropic medications, but also acknowledged that consents were not consistently obtained prior to therapy changes during the relevant period.