Failure to Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of antipsychotic medications for two residents. For one resident with diagnoses including anxiety, depression, and non-Alzheimer's dementia, and a severely impaired cognition score, the clinical record showed an order for Abilify was initiated. Although a nurse's note indicated that the resident's representative was spoken to about the medication's reason and benefits, there was no documentation of a completed medication consent form outlining the risks and benefits prior to starting the medication, as required by facility policy. Similarly, another resident with moderately impaired cognition and diagnoses including diabetes, heart failure, and coronary artery disease was started on Rexulti. The care plan noted the use of antidepressant medications, but again, there was no documentation of a completed medication consent form prior to the initiation of the medication. The DON confirmed that while staff had conversations with the residents' families regarding the medications, these discussions were not documented in the clinical notes.