Failure to Obtain Representative Consent Prior to Initiation of Antipsychotic Medication
Penalty
Summary
The facility failed to obtain and document informed consent from a resident’s appointed representative prior to initiating an antipsychotic medication, Zyprexa, as required by facility policy. The facility’s policy on Medication Administration Safety, Psychotropic Medications and New Medication Orders, dated 4/28/2025, states that any psychotropic medication requires resident or representative consent, including awareness of the medication ordered, its side effects, black box warnings when applicable, and the risks and benefits, and that consent is necessary prior to administration. The policy also requires that when a new medication is ordered, this is considered a change in condition and the representative must be notified, with evidence of this notification documented in the progress notes or other parts of the medical record. Record review showed that the resident was readmitted in October 2025 with encephalopathy and was rarely/never understood per a Minimum Data Set assessment, indicating that a Brief Interview for Mental Status was not conducted. A physician progress note dated 10/27/2025 documented that the resident had been pulling out a catheter and wound vac and refusing care, and an order for Zyprexa 5 mg for agitation was written. Medication Administration Records for October, November, and December 2025, and January 2026 showed that the resident received Zyprexa 5 mg daily from 10/27/2025 through 1/13/2026. Further review of the clinical record failed to reveal any evidence that the resident’s representative was informed of the Zyprexa order or of the risks, benefits, and alternatives to the medication. During an interview on 1/14/2026, the Director of Nursing Services was unable to provide evidence that the order for Zyprexa was reviewed with the resident’s representative prior to initiation of the medication.
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