Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document informed consent for the administration of a psychotropic medication to a resident diagnosed with hallucinations due to late onset dementia. The resident’s daughter, who held power of attorney, requested medication to address the resident’s increasing behaviors, resulting in an order for Quetiapine Fumarate (Seroquel) to be administered at bedtime. Although the care plan indicated that the family would be informed of the risks and benefits of psychotropic medication, and that consent should be obtained, there was no documentation in the electronic medical record that informed consent was provided to or signed by the resident’s daughter/POA prior to starting the medication. Interviews with facility staff, including the social worker, DON, and administrator, confirmed that while verbal education regarding the risks and benefits was provided, no signed consent form was obtained or scanned into the resident’s record. The facility had an existing consent form available at the time the medication was initiated, but it was not utilized. Additionally, the facility’s psychoactive drug monitoring policy did not reference the requirement for risk/benefit education or informed consent for residents or families.