Failure to Obtain Consent Prior to Administration of Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's responsible party was informed in advance of the risks and benefits of a proposed anti-anxiety medication, Alprazolam, and did not obtain proper consent prior to administration. The resident, an elderly female with severe cognitive impairment, dementia, depression, and anxiety, was admitted for hospice respite care. Her medical records indicated that she required partial to moderate assistance with activities of daily living and had a physician's order for Alprazolam to be given as needed for anxiety, with a specific instruction that the responsible party must be notified before administration. Despite these orders, Alprazolam was administered to the resident before consent was obtained from the responsible party. The medication consent form, which included information about potential side effects, was signed by the responsible party after the medication had already been given. Interviews with facility staff revealed that nurses were aware that consent should be obtained prior to administering anti-anxiety medications, and the facility's policy required written or verbal consent before starting such medications. However, the nurse who administered the medication was not aware of the requirement to notify the responsible party prior to administration and did not confirm that consent had been obtained. The responsible party reported not being educated on the risks or side effects of Alprazolam by the facility and explicitly stated that she did not give consent for its administration. She also noted that she had observed the hospice orders, which required notification before administration, and that both hospice and facility staff were aware of this requirement. The failure to obtain consent and notify the responsible party prior to administering the medication was confirmed through interviews and record review.