Failure to Inform Residents of Risks and Benefits Before Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents or their representatives were informed of the risks and benefits of psychotropic medications prior to their use, as required by resident rights. For one resident with traumatic brain injury and dementia with agitation, records showed ongoing administration of trazodone, risperidone, and buspirone per physician orders, with the MDS indicating significant cognitive impairment and use of antidepressant, antianxiety, and antipsychotic medications. However, there was no documentation that risks and benefits were discussed before these psychotropic medications were administered. Another resident with severe cognitive impairment, emotional lability, and dementia had an order for trazodone 50 mg twice daily with medication monitoring, but the EMR contained no record of any risk-versus-benefit discussion with the resident or representative prior to starting the medication. A third resident, cognitively intact with a diagnosis of depression, was started on sertraline 25 mg daily, yet the EMR lacked documentation that risks and benefits were reviewed before initiation. A fourth resident with severe cognitive impairment, multiple neurological and psychiatric diagnoses, and existing use of antipsychotic and antianxiety medications had a care plan noting risk for adverse reactions related to psychotropic use and a physician order for risperidone 0.5 mg twice daily for dementia with severe agitation. Despite this, there was no documentation that the risks and benefits of this psychotropic medication were reviewed with the responsible party prior to initiation. During an interview, the Administrator, DON, and Regional President of Operations confirmed that risk-versus-benefit discussions for psychotropic medications had not been conducted for at least one of the residents, despite the facility’s resident rights document stating that residents have the right to be fully informed of the risks and benefits of proposed treatments.
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