Failure to Obtain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper informed consent for the administration of psychotropic medications to a resident with severe cognitive impairment and no decision-making capacity. Record review showed that the resident, who had diagnoses including paranoid schizophrenia, restlessness, agitation, and emotional lability, was assessed as having significant cognitive impairment and was determined by a physician to lack the capacity to understand or make medical decisions. Despite this, informed consent for the administration of Vistaril and trazodone was documented as being obtained directly from the resident. Interviews with the Director of Nursing confirmed that staff should not have obtained consent from the resident, given the lack of decision-making capacity. Facility policy required that the risks and benefits of psychotropic medications be explained prior to use, and that consent be obtained from the resident or a responsible party. The failure to follow these procedures resulted in the administration of psychotropic medications without valid informed consent.