Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents were informed of psychotropic medication side effects and the associated risks versus benefits, as required by facility policy. One resident with bipolar disorder, major depressive disorder (MDD), and anxiety had an intact cognition with a BIMS score of 14/15 and was receiving buspirone for anxiety, duloxetine for MDD, and risperidone for delusional disorder. Review of the electronic medical record (EMR) showed no documentation of consent or any risk-versus-benefit discussion regarding these psychotropic medications with the resident or a representative. In an interview, this resident stated she had been told what medications she was on but not about potential effects related to the medications. The DON confirmed there was no documentation specific to review of potential effects of psychotropic medications with the resident or representative, despite the policy requiring such education and documentation. Another resident, admitted and later readmitted with diagnoses including MDD and anxiety disorder, had an intact cognition with a BIMS score of 15/15 and was receiving buspirone for anxiety and duloxetine for depression. EMR review similarly revealed no documentation of consent or risk-versus-benefit review for these medications. In an interview, this resident reported not remembering any discussion with staff about medication effects and was unsure of what medications she was taking. The DON stated there was no documentation of any staff conversation with this resident regarding risks versus benefits for the medications. Review of the facility’s psychoactive medications policy, last reviewed on 01/13/26, showed that residents are to be educated on the benefits and potential risks of these drugs and that such education is to be documented in the medical record, which did not occur for these two residents.
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