Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to inform a resident's responsible party in advance about the risks and benefits of a newly prescribed psychoactive medication, as well as treatment alternatives or other options. The responsible party expressed concerns regarding the resident's increased number of falls and the initiation of a new medication for sleep, but was unable to identify the medication. Record review showed that the resident was started on Trazodone 25mg as needed for insomnia, and received the medication on several occasions before any documented informed consent was obtained from the responsible party. Facility policy requires written consent and documentation of discussions regarding the risks and benefits of psychotropic medications prior to administration. However, there was no evidence that informed consent was obtained or that the responsible party was notified before the medication was administered. Documentation showed that only after the medication had been given multiple times was a message left for the responsible party, and verbal consent was documented more than three weeks after the initial order. Interviews with facility staff confirmed the lack of timely documentation and consent.