Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from the use of chemical restraints by administering psychotropic medications without obtaining the required consent. Specifically, a resident with severe cognitive impairment and a diagnosis of unspecified dementia with behavioral disturbances was given Haldol, an antipsychotic medication, and Sertraline, an antidepressant, without documented consent from the resident's representative. The facility's policy required consent for the use of antipsychotic and psychoactive medications, but the Director of Nursing confirmed that no such consent was found for either medication. The resident's representative discovered the use of Haldol only after requesting a list of medications and reported being unaware of its administration, never having signed a consent form. Medication records showed that Haldol was administered over several weeks and Sertraline was ongoing, with no evidence of informed consent being obtained. The Minimum Data Set confirmed the resident was receiving both antipsychotic and antidepressant medications during this period.