F0605

D

Psychotropic Medication Administered Without Required Consent

Tucson, Arizona Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain a signed consent from the responsible party before initiating a new psychotropic medication, Hydroxyzine, for Resident #4. The resident was admitted with dementia with associated psychotic, mood, and anxiety disturbances, a history of UTIs, and repeated falls. An admission MDS showed a BIMS score of 02, indicating cognitive impairment, and documented behaviors including physical and verbal symptoms, other behavioral symptoms interfering with care and activities, rejection of care, and wandering. On February 3, 2026, a psych evaluation note ordered Hydroxyzine 50 mg by mouth every 6 hours as needed for anxiety manifested by calling out, and the MAR showed that the resident received four doses between February 3 and February 7, 2026.

Review of the clinical record did not reveal a signed consent for the Hydroxyzine 50 mg order. LPN Staff #10 stated that consents for psychotropic medications are to be obtained at admission and must be signed by the resident or responsible party prior to administration, with verbal consent allowed if the family cannot come in to sign. After reviewing the record, Staff #10 confirmed she could not locate a signed consent for Hydroxyzine, acknowledged the medication should not have been administered without consent, and reported that the family member knew the medication was being given. She further stated that the family member had agreed to the medication during a care plan meeting but ultimately decided not to sign the consent form, and she herself had not attended that meeting.

The Behavioral Health Unit Manager (LPN Staff #37) and LPN Staff #86 both confirmed that there was no signed consent for Hydroxyzine in the chart, despite the medication having been administered four times. Staff #37 stated that nurses are not to administer Hydroxyzine without a signed consent and that administration without consent was not in accordance with protocol. Staff #86 reported that the resident had been on Mirtazapine, that the family did not want the resident on Seroquel, and that the family wanted non-pharmacological interventions tried first, while acknowledging that a signed consent was required before administering Hydroxyzine. The DON (Staff #22) explained that the nurse who enters or verifies a psychotropic order is responsible for obtaining consent and that nurses are expected to check the system for a signed consent before administering such medications. She confirmed that no signed consent for Hydroxyzine could be found and that the medication had been administered four times without it. The facility’s psychoactive drug use policy stated that residents and/or responsible parties will be asked to make an informed choice concerning psychoactive drug use, with risks and benefits explained.