F0552

D

Failure to Obtain HCS Consent Prior to Psychotropic Medication Changes

Lake Placid, Florida Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Health Care Surrogate (HCS) prior to initiating and changing psychotropic medications. The resident, who had diagnoses including other specified mood disorders, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorders, was admitted in 2025 and had severe cognitive impairment as evidenced by a BIMS score of 3 on a later MDS. The HCS reported that the facility did not communicate medication changes before they were implemented, specifically noting the initiation of Haldol and Depakote after the resident exhibited behavioral issues. The HCS expressed being upset that these changes were not communicated in advance.

Interviews with staff confirmed that facility practice and expectation were that the HCS should be notified and consent obtained before starting psychotropic medications. Staff A, an LPN, stated that the unit manager was supposed to notify the family before starting psych medications and that there was no reason not to notify the HCS prior to initiating such medications; Staff A also stated the HCS had refused psychotropic medication for the resident. Staff B, an LPN and Unit Manager, described the process for obtaining psychotropic consent, including calling the HCS, explaining risks, documenting verbal consent on a psychotropic medication form, and uploading the form and a progress note to the medical record. However, Staff B acknowledged that Haldol was ordered on 04/11/2025 and administered on 04/26/2025, and that Depakote had been administered and later dose-adjusted in April 2025, without a psychotropic consent form signed prior to those administrations.

Record review corroborated that the resident received multiple psychotropic medications before documented consent was obtained. The MAR showed administration of divalproex sodium 125 mg from 04/01/2025 through 04/13/2025, Depakote ER 250 mg from mid- to late April 2025, Depakote ER 500 mg starting 04/28/2025, and a Haldol injection on 04/26/2025. A psychotropic medication administration disclosure/consent form was dated 04/28/2025, and Staff B stated this was the first psychotropic consent form seen for Depakote, acknowledging it should have been signed before the resident received Depakote and Haldol. Progress notes documented behavioral issues and the use of Haldol for severe agitation, as well as a late entry note on 04/28/2025 indicating that a behavioral health provider assessed the resident and that a family member gave consent for medication at that time. The DON confirmed that consent should have been obtained for Haldol and Depakote prior to administration, that families were typically contacted before psychotropic medications were given, and that there was no documentation in the record confirming that the provider had notified the family before the medications were started.