Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident and/or their representative were informed in advance about prescribed medications and understood the reasons, risks, and benefits, resulting in a lack of informed consent for psychotropic medications. Record review for Resident #3 showed physician orders for Lorazepam 0.5 mg by mouth twice daily for anxiety starting 09/09/25, and Hydroxyzine HCL 25 mg by mouth twice daily for anxiety starting 10/22/25. Further review of the medical record revealed there were no consent forms for the use of either Lorazepam or Hydroxyzine. In an interview on 12/05/25 at 1:22 p.m., the DON confirmed that staff did not obtain the required psychotropic medication consent forms prior to initiating these medications for Resident #3, despite the expectation that such consent be completed before starting psychotropic drugs. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.
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