Failure to Inform Resident Representatives of Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to inform resident representatives in advance about the risks, benefits, and treatment alternatives prior to initiating or increasing psychotropic medications for two residents. Facility policy requires that before starting or increasing psychotropic medications, the resident, family, or representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotics, and that this communication must be documented. For one resident with severe cognitive impairment and diagnoses of dementia and anxiety, Buspar was initiated for agitation without documented evidence that the representative was informed in advance of the medication's risks, benefits, or alternatives. The Director of Nursing confirmed the absence of such documentation in the clinical record. For another resident with cognitive impairment and diagnoses of dementia, depression, and anxiety, Seroquel was increased and later further adjusted due to behavioral escalation and agitation. Although nursing notes indicated that the representative was notified of dosage changes, there was no documented evidence that the representative was informed in advance of the risks, benefits, or treatment alternatives prior to the medication changes. The Director of Nursing confirmed that the required documentation was not present in the clinical record for these medication adjustments.