Failure to Obtain and Document Consent for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia, anxiety disorder, major depressive disorder, and bipolar disorder, was administered Haldol, an antipsychotic medication, without documented prior consent. The resident had a BIMS score indicating severe cognitive impairment and was receiving antipsychotic medication on a routine basis. The care plan and physician orders reflected the use of Haldol for aggression and schizophrenia, with a new order for Haldol injection given after the resident became verbally aggressive and refused morning medications. The Assistant Director of Nursing (ADON) reported that she contacted the resident's responsible party (RP) by phone and obtained verbal consent before administering the Haldol injection. However, she failed to document this verbal consent in the resident's progress notes. Additionally, the required written consent form was not received or uploaded into the resident's electronic medical record, and the ADON was unable to locate an email attachment of the consent form sent to the RP. The Director of Nursing (DON) confirmed that the facility's protocol required verbal consent prior to administration and written consent afterward, but the written consent was not obtained or documented as required. Facility policy mandates that residents or their representatives be informed of the benefits, risks, and alternatives to psychotropic medications prior to initiation or increase, and that this consent be documented in the medical record. In this case, the lack of documentation for both verbal and written consent for the administration of Haldol constituted a failure to ensure the resident's right to be informed and to provide consent for treatment.