Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from the responsible party prior to administering Depakote, an anticonvulsant medication, to a resident diagnosed with schizoaffective disorder, schizophrenia, and depression. The resident was determined to lack the capacity to make healthcare decisions, and a responsible party was designated to make such decisions on their behalf. Despite this, there was no documented verification that the responsible party was informed about the risks, benefits, and alternatives to Depakote before it was administered for mood disorder symptoms, specifically angry outbursts. Interviews with facility staff confirmed that the process for obtaining informed consent required the physician to explain the medication and its effects to the responsible party, with nursing staff responsible for verifying that consent was obtained before administration. Record review showed that while informed consent documentation existed for other antipsychotic medications, none was present for Depakote. Facility policies also required that residents or their representatives be informed and involved in medication management, including the right to refuse treatment, but this process was not followed in this instance.