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F0552
D

Failure to Obtain Informed Consent Prior to Administration of Psychotropic Medication

New Holstein, Wisconsin Survey Completed on 09-12-2025

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 ensure that a resident or their legal representative was informed in advance of the risks and benefits of a prescribed medication, naltrexone, and did not obtain consent prior to its administration. According to the facility's policy, residents or their representatives must be informed and provide consent before initiating or increasing psychotropic medications. In this case, the resident had an activated Power of Attorney for Healthcare (POAHC), and the medical record indicated that the resident was prescribed naltrexone for sexualized behaviors. The medication was administered without documented consent or prior notification to either the resident or the representative. Interviews and record reviews revealed that the resident had intact cognition and relied on their representative to consent to medications and treatments. The Director of Nursing (DON) confirmed that consent for naltrexone was only obtained after the medication had already been administered, and that the representative later revoked consent upon learning about potential side effects. The resident expressed being upset about not being informed or consulted before receiving the medication, which was against their rights as outlined in facility policy.

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