Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained for psychotropic medications prescribed to a resident with severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, and hypertension, was readmitted to the facility with orders for multiple psychotropic medications. Documentation indicated that the resident was severely impaired in cognitive skills and required substantial assistance with daily activities. Upon review, it was found that the facility continued the psychotropic medication regimen initiated during a recent hospital stay without verifying or obtaining new informed consent from the resident's representative. Interviews with the resident's daughter revealed that medication changes, specifically an increase in depression medication dosage, were made without her notification. The Social Service Director and MDS Nurse confirmed that the medication changes occurred during the resident's hospital stay and were continued upon readmission to the facility. However, there was uncertainty about whether proper notification or consent had been obtained for these changes. The facility's records included informed consent forms for the psychotropic medications, but the psychiatric nurse practitioner stated that they did not actually obtain consent from the resident's representative as indicated on the forms. The facility's policy required verification of prior informed consent for psychoactive medications upon admission or readmission, and if such documentation was not present, the admitting physician was responsible for obtaining consent. In this case, there was no verified documentation from the discharging hospital, and the admitting provider did not obtain informed consent from the resident's representative. This resulted in the resident receiving psychotropic medications without the required informed consent process being completed.