Failure to Obtain and Document Informed Consent for Psychotropic and Related Medications
Penalty
Summary
The facility failed to ensure that residents or their guardians were fully informed about the medications they were receiving, including the reasons for use, risks, and benefits. For two of three residents reviewed for unnecessary medications, there was no documentation in the electronic medical record of signed consent forms for prescribed medications such as antidepressants, anticonvulsants, antianxiety, and antipsychotic drugs. Specifically, one resident was prescribed Escitalopram, Depakote, Quetiapine, and Hydroxyzine for conditions including depression, anxiety related to traumatic brain injury, and agitation, but no consent forms were found in the record for any of these medications. Similarly, another resident was prescribed Citalopram and Hydroxyzine for depression and anxiety related to dementia, but again, no signed consent forms were present in the medical record. During interviews, the DON confirmed that there should have been signed consent forms for these medications. The lack of documented consent indicates that residents or their responsible parties were not adequately informed about the medications being administered.