Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for psychotropic medications, as evidenced by record reviews for two residents. One resident had diagnoses including major depressive disorder with psychotic features and generalized anxiety disorder and had physician orders for quetiapine and lorazepam, with a history of being on these types of medications for several months. The resident’s clinical record contained a Psychotropic Medication Treatment Consent form that incorrectly listed the treatment reason as Tracheotomy/Brain Damage, left the medication section blank, and was signed by the resident’s representative. The record did not contain documentation that the resident or representative had been educated on the risks, benefits, side effects, or other adverse reactions associated with the ordered antipsychotic and antianxiety medications. Another resident had diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, and major depressive disorder, and had physician orders for olanzapine, buspirone, and escitalopram. This resident’s Psychotropic Medication Treatment Consent form had both the condition being treated and the medications being used left blank, although it was signed by the resident’s representative. The clinical record similarly lacked documentation that the resident or representative had been informed of the risks and benefits, including side effects and adverse reactions, of the antipsychotic, antianxiety, and antidepressant medications. During an interview, the NHA stated that the facility’s practice was to obtain a psychotropic consent at admission only and not to obtain additional consents, and that staff would review medication changes with representatives and document these discussions in progress notes; however, no such documentation was found for these two residents.
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