Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document consent from residents' representatives for the use of psychotropic medications for two residents reviewed for unnecessary medications. For one resident with diagnoses including anxiety disorder, dementia, and borderline personality disorder, the clinical record and care plan indicated regular use of antipsychotic medication. Despite multiple requests, staff were unable to provide a signed consent form for the psychotropic medication, and the required documentation was not available in the resident's record or psychiatric consultant notes. The facility's policy required involvement and documentation of the resident or representative in discussions about medication risks and benefits, which was not followed in this case. For another resident with dementia, diabetes, and chronic kidney disease, the clinical record also failed to show evidence that the resident's representative was informed of the risks and benefits of psychotropic medication use or that consent was obtained. Staff interviews confirmed that the consent form could not be located, and although a psychiatric note indicated the resident consented, the resident was cognitively impaired and conserved, making representative consent necessary. No documentation was provided to show that the conservator had given consent for the medication.