Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, risperidone, for one resident diagnosed with non-Alzheimer's dementia and depression. Clinical record review showed that the resident had moderate cognitive impairment, as indicated by BIMS scores of 9 and 11 on separate assessments. The resident began receiving risperidone on a routine basis, as documented in progress notes and the Minimum Data Set (MDS) assessments. However, there was no documentation of informed consent from the resident's responsible party for the use of this psychotropic medication during the period from when the medication was initiated through the time of the survey. Staff interviews confirmed that the process for obtaining consent was not followed, with the Licensed Practical Nurse stating that the nurse who received the order should have contacted the family or resident to obtain and document consent in the chart. The facility's policy on antipsychotic medication use, dated 12/2016, requires that informed consent be obtained, but review of the resident's evaluations and care plan revealed no such documentation. The care plan also failed to include the use of the antipsychotic medication.