F0552

D

Failure to Obtain Informed Consent for Psychotropic Medications

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain informed consent and notify the responsible party (RP) prior to initiating psychotropic medications for a resident. The resident was admitted with diagnoses including stroke and non-Alzheimer’s dementia and was assessed as severely cognitively impaired, with no behaviors, and receiving antidepressant medications. Physician orders showed mirtazapine 7.5 mg at bedtime starting on 10/7/25 and trazodone 100 mg in the afternoon starting on 11/13/25 for depression, and the Medication Administration Record for January 2026 indicated these medications were administered daily. The medical record contained no documentation that the RP was informed in advance of the risks and benefits of these psychotropic medications, the treatment alternatives available, or that consent was obtained, and attempts to reach the RP were unsuccessful.

Interviews with facility staff revealed confusion and inconsistency regarding responsibility for obtaining psychotropic medication consents. The ADON stated she was unsure who was responsible for obtaining consent. The DON acknowledged awareness that some psychotropic consents were not signed because the SW, who had been responsible for obtaining consents, was not always informed by nursing when new psychotropic medications were ordered. The SW confirmed she had been responsible for obtaining consents and relied on nursing staff to notify her of new psychotropic orders, which did not always occur, resulting in missed consents. The NP stated that nursing staff were responsible for obtaining consent for newly prescribed psychotropic medications. The Administrator stated she was not aware that this resident lacked signed consents for mirtazapine and trazodone, although she knew consents should have been obtained prior to implementation of these medications.