Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering a one-time dose of Ativan, an anti-anxiety medication, to a resident. The resident, an elderly female with multiple diagnoses including diabetes, COPD, hypertension, and a history of anxiety, experienced a change in condition characterized by agitation, refusal of medication and hospital transfer, and vital sign abnormalities. The nurse practitioner ordered Ativan to manage the resident's acute behavioral distress and facilitate safe transport to the hospital. However, there was no documentation or recollection by the LVN that informed consent was obtained before administering the medication, despite the resident being described as self-responsible and able to make her own decisions. Facility policy requires that informed consent be obtained by the prescriber prior to the initiation of any psychotropic medication, including anxiolytics such as Ativan. The DON confirmed that consent is required before administering such medications. The lack of documented informed consent prior to giving Ativan constituted a failure to ensure the resident's right to make an informed decision about her care, as required by facility policy and applicable regulations.