Failure to Obtain Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that consent forms were properly completed or signed by a responsible party prior to administering a psychotropic medication, Remeron (Mirtazapine), to a resident. The resident, an adult male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was admitted with intact cognitive function as indicated by a BIMS score of 15. Despite this, review of the resident's records showed that Remeron was administered as an appetite stimulant over several days without obtaining the required signature or verbal consent from the resident or responsible party. Interviews with facility staff, including an LVN and the DON, confirmed that the established protocol required nurses to obtain either a written or verbal consent before administering psychotropic medications. The facility's policy also mandated that residents or their representatives be informed of the benefits, risks, and alternatives to the medication prior to initiation, and that this consent be documented. However, documentation revealed that the medication was given without the necessary consent, and staff acknowledged that this was not in accordance with facility policy or resident rights.