Failure to Obtain and Document Informed Consent for High-Risk Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed about their health status, care, and treatments, specifically regarding the risks and benefits of prescribed medications and available treatment alternatives. For one resident with chronic anxiety, multiple orders for Lorazepam were present in the medical record, but there was no evidence that the resident or their representative was educated on the use, risks, or benefits of this high-risk medication. Facility policy requires education and documentation for high-risk medications, but interviews with the Unit Manager and DON confirmed that consent forms were not used for Lorazepam, and no signed consent was found in the electronic medical record. Another resident had a documented verbal consent for an antipsychotic medication, Olanzapine, at a lower dose, but when the dose was increased, there was only a note indicating a message was left for the responsible party, with no further documentation of notification or consent. Additionally, this resident was prescribed Citalopram, an antidepressant, without documented evidence that the responsible party was informed of the risks, benefits, or alternatives. Facility policies require signed consent forms and education for antipsychotic and high-risk medications, but staff interviews confirmed that these requirements were not met for the residents involved.