Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were informed in advance about the medications being administered, including the reasons, risks, and benefits associated with those medications. Record review showed that the resident had multiple diagnoses, including major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, and unspecified mild dementia with mood disturbance. The resident was prescribed several medications, including buspirone, hydroxyzine, Tylenol PM Extra Strength, and venlafaxine, for these conditions. Despite these prescriptions, the medical record did not contain any consent forms for the use of these psychotropic medications. During an interview, the DON confirmed that staff did not obtain the required psychotropic medication consent forms prior to starting these medications, as expected by facility policy. This lack of documented consent meant the resident and/or their representative were not fully informed about the medications being administered.