Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident. The resident was admitted with multiple diagnoses, including dementia and diabetes. On 1/21/26, a physician ordered Sertraline 25 mg once daily for depression. Record review showed there was no psychotropic medication acknowledgement consent on file for this resident’s current use of Sertraline. On 2/18/26 at 3:16 PM, the LSW confirmed there was no psychotropic medication acknowledgement consent for the resident, and at 3:18 PM, the MDS RN stated the resident should have signed a psychotropic medication acknowledgement consent prior to administration of Sertraline but had not. This lack of documented informed consent before starting the psychotropic medication constituted the identified deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.