Failure to Obtain Consent for Psychoactive Medication Administration
Penalty
Summary
Facility staff failed to obtain consent from a resident prior to administering a psychoactive medication, Ativan, on 3/1/25. The resident was assessed as having no cognitive impairment, scoring 15 out of 15 on the BIMS, and was identified as her own responsible party. Clinical records showed no change in cognitive status and documented that the resident was offered Ativan orally, which she refused. Despite this, staff proceeded to administer Ativan by intramuscular injection without evidence that the resident was given the opportunity to consent to or refuse the injection. Staff interviews confirmed that facility policy requires resident or responsible party notification and consent prior to medication administration, and that residents have the right to refuse any medication or treatment. The staff acknowledged that, although non-pharmacological interventions were attempted and the resident refused the oral medication, there was no documentation or evidence that the resident was given the opportunity to refuse the Ativan injection. Facility policy also states that all patients have the right to refuse medications, and that nurses are responsible for providing education regarding risks, but no such documentation was found in this case.