F0551

D

Failure to Obtain Guardian Consent for Psychotropic Medication Change

Waterville, Maine Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a court-appointed public guardian was notified and able to exercise decision-making rights regarding a resident’s medication change. A resident with a court order dated 10/31/18 appointing the Department of Health and Human Services as full public guardian and conservator had an increase in Lithium, a mood stabilizer and antimanic agent, from 300 mg twice daily to 450 mg twice daily for increased hallucinations and delusions. The resident’s care plan, last revised 9/11/25, documented that the state guardian would be involved in decisions and that informed consent would be provided to the resident or healthcare decision maker for psychotherapeutic medications. Despite these documented interventions, the clinical record lacked evidence that the Lithium dose increase was discussed with or consent obtained from the guardian.

In interviews, the facility’s social worker stated that for any change in condition or need to send a resident out, nursing is to call and get approval from the guardian for anything requiring a decision. However, the resident’s Public Guardian Representative reported that the primary provider increased the Lithium dose without obtaining the guardian’s consent. Email correspondence between the facility and the guardian showed the guardian later raised concerns that the facility failed to obtain consent for treatment and medication changes, clarifying that a phone call with voicemail or an email notification of what is going to be done does not constitute consent. The guardian specifically stated they learned after the fact that the Lithium had been changed and emphasized that the resident was unable to provide their own consent, which was the reason for the state guardianship.