Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration for one resident. Resident #98 was admitted with diagnoses including bipolar disorder, dementia, and anxiety, and had physician orders dated 01/07/26 for multiple psychotropic medications: Amitriptyline 25 mg, two tablets in the evening for bipolar disorder; Depakote Sodium ER 500 mg, three tablets in the evening for dementia; and Seroquel 300 mg, one tablet in the evening for dementia. The Medication Administration Record from 01/07/26 through 01/15/26 showed that these medications were administered as ordered during this period. The admission MDS assessment documented that the resident was cognitively intact and received antipsychotic, anticonvulsant, and antidepressant medications during the assessment period. Record review revealed no documentation that Resident #98 or a resident representative had consented to, or had been informed in advance of, the risks versus benefits of receiving Seroquel and Amitriptyline. Unit Manager #2 explained that the admission packet includes a checklist, with item #6 being the psychotropic medication consent form that should be reviewed and signed and is located in the electronic record; upon review of the electronic record, she confirmed there was no documentation of this consent or of a risks-versus-benefits discussion. The Nurse Practitioner stated that the psychotropic consent form should have been completed upon admission and that it was important for the nurse to inform the resident of the risks versus benefits of each psychotropic medication prior to administration. The DON similarly reported that the psychotropic consent form should have been completed by the admitting nurse at admission, with risks versus benefits discussed for each ordered psychotropic medication before the medications were given.
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