Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent prior to initiating a psychotropic medication for a resident. The resident was admitted with diagnoses including depression, anxiety disorder, insomnia, and homelessness. An MDS assessment dated 12/30/2025 documented moderately impaired cognition, with the resident needing setup assistance for eating and partial assistance for other ADLs. The physician’s orders, covering 12/24/2025 to 12/31/2026, included a new order starting 12/25/2025 for quetiapine fumarate 50 mg by mouth at bedtime for depression manifested by verbalized feelings of hopelessness and agitation. During a concurrent interview and record review, RN 1 confirmed that staff did not obtain informed consent before administering the quetiapine, and that administration began on 12/25/2025. In a separate interview, the DON stated that informed consent should be obtained prior to the administration of psychotropic medications. Review of the facility’s policy titled “Psychotherapeutic drug informed consent,” revised 1/2026, showed that the facility policy requires residents and/or their representatives to be fully informed of the benefits, risks, frequency/duration, possible side effects, and alternative approaches before starting psychotherapeutic drugs. Despite this policy, informed consent was not obtained for this resident before the psychotropic medication was administered.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.