Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided written consent prior to the administration of an antipsychotic medication, Invega Sustenna, as required. Record reviews showed that the resident, who had a diagnosis of paranoid schizophrenia and a moderately impaired cognitive status, received the medication over several months without a completed HHSC Form 3713 or other documented consent in the electronic health record. Interviews with facility staff, including the Regional Compliance Nurse, ADON, DON, and administering RN, confirmed that no consent was obtained or documented for this medication. The resident herself reported not being asked to sign a consent for Invega Sustenna and not being informed about the risks and benefits of the medication. Facility policy required that residents be informed of and participate in their treatment, including being made aware of the risks, benefits, and alternatives to psychotropic medications before initiation. Despite this, the required consent process was not followed for this resident. Staff interviews revealed a lack of awareness regarding the missing consent, and the resident's care plan indicated the need for education about the medication, which was not documented as provided. The deficiency was identified through interviews, record reviews, and policy examination, all indicating a failure to obtain and document informed consent for the administration of a psychoactive medication.