Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or their representative was informed about and consented to the use of a psychotropic medication, specifically Risperdal. The facility’s “Behaviors: Management of Symptoms” policy, revised on 09/15/25, required that residents exhibiting behavioral symptoms be individually evaluated and that consent be obtained from the resident or representative when medication is ordered for behavioral symptoms. One resident, originally admitted with a diagnosis of unspecified dementia with agitation, had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Nursing progress notes showed that on 08/04/25, the primary care physician determined a gradual dose reduction was contraindicated due to ongoing behaviors and ordered Risperdal 1 mg. Physician orders documented multiple Risperdal 1 mg orders beginning in early August 2025 for delusions, mood changes, and severe unspecified dementia with agitation, with the final order remaining active. The medication administration records for September, October, and November 2025 showed that Risperdal was administered daily during those months. Review of psychotropic medication consent forms revealed consents for Quetiapine and Seroquel on several dates, but no consent form for Risperdal. During an interview, the DON stated that when a psychotropic medication is determined to be needed, staff are to obtain consent within 24 hours, either by resident signature or verbal consent from family, and that all nurses are responsible for obtaining consent forms. The DON confirmed that there was no consent form for Risperdal for this resident and that there should have been one.
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