Failure to Obtain Informed Consent and Document Behaviors for Psychotropic Dose Increases
Penalty
Summary
The deficiency involves the facility’s failure to follow its psychotropic medication policy by not obtaining informed consent for multiple increases in a resident’s Seroquel (quetiapine) dosage and by not documenting behaviors or non-pharmacological interventions to justify those increases. The resident, who has a history of major depressive disorder, schizoaffective disorder, morbid obesity, iron deficiency anemia, and vitamin D deficiency, reported being concerned that staff were giving him higher doses of Seroquel than the 100 mg he believed he should receive and stated he did not consent to the dosage changes and had been refusing the medication. Record review showed that his Seroquel dose was progressively increased from 100 mg at bedtime to as high as 600 mg at bedtime over several physician orders. When surveyors requested consent documentation for these increases, the facility produced a form that the resident had refused to sign, and there was no documentation that the resident’s guardian had been informed of or consented to the dosage increases, despite the facility’s policy requiring informed consent from the resident or guardian for psychotropic medications and dosage increases. Behavior monitoring records ordered for the resident showed no documented behaviors for the months reviewed, even though the resident’s guardian reported he had requested a medication review because the resident was always worrying about others and frequently calling the police, and believed the resident was on 100 mg of Seroquel without being informed of any increases. The ADON acknowledged that if a resident is not exhibiting behaviors, they probably should not be on psychotropic medications and confirmed that the behavior monitoring sheets showed no behaviors. A psychiatrist and a psychiatric nurse practitioner both stated that staff were supposed to document behaviors as ordered and that informed consent was required for psychotropic medications and dosage increases, but also indicated they based treatment decisions on their observations and staff reports. An LPN reported that the resident wanted the Seroquel decreased, but the psychiatric team refused, and she was not aware of any behaviors. The facility’s psychotropic medication policy required routine documentation of behaviors and resident response to the medication, as well as informed consent prior to prescribing psychotropic medications, which was not followed in this case.
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