Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, as required by its own policy. For one resident with severe dementia and psychotic disturbance, medical records showed the ongoing administration of Sertraline, an antidepressant, from June through September, without any documented consent for its use. This resident had a significant cognitive impairment, as indicated by a low BIMS score, and received the medication daily as ordered by the physician. Another resident, who had moderate cognitive impairment and multiple psychiatric diagnoses, was administered several psychotropic medications, including Alprazolam, Buspirone, Sertraline, and Trazodone, over a similar period. Review of the medical record for this resident also revealed no documented consent for any of these medications. During an interview, the DON confirmed that the nurse responsible for admitting residents was tasked with obtaining these consents, but acknowledged that the required consent forms were not obtained for either resident.