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F0552
D

Failure to Obtain Timely Informed Consent for Psychotropic Medications

Springfield, Vermont Survey Completed on 11-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain and document informed consent for psychotropic medications for a resident, as required. Upon admission, the resident had physician's orders for an antidepressant (Protriptyline) and an antipsychotic (Aripiprazole). While a consent form for antipsychotic medications was completed and signed by the resident's guardian, it did not include the antidepressant Protriptyline. The consent form for antidepressant medication was found to be blank and unsigned, with no evidence that informed consent was obtained for Protriptyline prior to administration. Additionally, a new antipsychotic medication (Quetiapine) was ordered for the resident, but the documentation of verbal consent from the guardian for all psychotropic medications was not completed until after both Protriptyline and Quetiapine had already been initiated. The resident's care plan included an intervention to provide informed consent to the resident or healthcare decision maker, but this was not carried out in a timely manner. The facility administrator confirmed that the required consent documentation was not completed until after the medications had been started.

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