F0552

D

Lack of Informed Consent Documentation for Psychotropic Medications

Seaford, Delaware Survey Completed on 06-13-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments when multiple psychotropic medications were initiated without documented discussion of risks and benefits. The resident was admitted on 9/12/24 and had an admission MDS on 9/18/24 showing a BIMS score of 6, indicating severe cognitive impairment. Subsequent physician orders included buspirone 5 mg by mouth every morning and at bedtime for anxiety on 2/13/25, lorazepam 0.5 mg by mouth every six hours for generalized anxiety disorder for 14 days on 3/3/25, and haloperidol 5 mg/mL intramuscularly every four hours as needed for agitation on 3/9/25. During interviews, an RN (E11) stated the facility’s expectation was to review each new psychotropic medication’s risks versus benefits with the resident if cognitively intact or with the resident’s representative, and that a specific form was used for these discussions. Another RN (E6) confirmed that the resident’s medical record lacked a Psychotropic Medication Administration Disclosure form for buspirone, haloperidol, and lorazepam (Ativan), and that the physician’s progress notes also lacked documentation of risk-versus-benefit discussions for these medications. These findings were later reviewed with the NHA, DON, and corporate representative.