Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration and changes of psychotropic medications for one resident with severe cognitive impairment. The resident, who had diagnoses including psychotic disorder with delusions, depression, and unspecified dementia with agitation, was prescribed multiple psychotropic medications such as Duloxetine, Mirtazapine, Olanzapine, and Quetiapine. Despite the resident's cognitive status, there was no evidence that informed consent was obtained from the resident's representative prior to the initiation or adjustment of these medications. Family members reported they were not notified about changes to the resident's medications and only became aware of the use of certain psychotropic drugs after reviewing a medication list provided by the facility. The family expressed concern and confusion regarding the reasons for the prescriptions, indicating a lack of communication and education from the facility regarding the resident's medication regimen. The resident's spouse/guardian was not fully informed about all medications until a care conference was held, well after the medications had been prescribed and administered. Interviews with facility staff, including the social worker and the nursing home administrator, confirmed that there were no signed consent forms for the psychotropic medications in the resident's medical record, except for verbal consent documented during a care conference. The social worker acknowledged that, given the resident's severe cognitive impairment, consent should have been obtained from the spouse/guardian rather than the resident. The director of nursing also confirmed that consent is required for the administration of psychotropic medications, but such documentation was not present.