Failure to Obtain Informed Consent Prior to Initiation of Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident representative prior to initiating a psychotropic medication. A resident with diagnoses including depression, knee surgery, and congestive heart failure was initially admitted and later readmitted to the facility. A History and Physical dated 9/12/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 1/7/2026 indicated the resident was independent in cognitive skills for daily decision making, though requiring moderate assistance with some activities of daily living. On 2/2/2026, a physician placed a telephone order for Cymbalta 30 mg by mouth in the morning for depression, and the Medication Administration Record showed the resident received this medication daily from 2/4/2026 to 2/24/2026. During an interview and concurrent record review on 2/24/2026, the ADON confirmed there was no documentation in the clinical record indicating that informed consent for Cymbalta had been obtained from the resident’s representative, despite the admission record identifying that the resident had a representative. The ADON stated that facility staff cannot initiate any psychotropic drug until the physician obtains informed consent from the resident’s representative and acknowledged that no such consent was present in the chart. The DON stated that not obtaining informed consent prior to initiating any psychotropic drug is a violation of resident rights and that residents or their representatives have the right to make an informed decision to accept or decline psychotropic medications. Review of the facility’s policy on Psychotropic Medication Use, dated 3/2025, showed that prior to initiating, increasing, or switching psychotropic medications, staff and the physician are required to review non-pharmacological interventions, indications and rationale, potential risks and benefits, and the right to accept or decline treatment with the resident or representative before obtaining documented consent or refusal.
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