Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to inform a cognitively intact resident or her representative about the risks and benefits of multiple psychotropic medications, including an antianxiety, antidepressant, and antipsychotic. The resident’s EMR documented diagnoses of anxiety, depressive disorder, and drug-induced dyskinesia, and her MDS showed a BIMS score of 15, indicating intact cognition. The MDS and Psychotropic Drug Use CAA documented that she received high-risk psychotropic medications, including two antidepressants and an antianxiety medication, with identified risk factors such as falls and injuries related to falls. Her care plan documented use of an antidepressant for depression, an antianxiety medication for anxiety with a directive to educate the resident and family on risks, benefits, and side effects, and an antipsychotic medication. Physician’s orders showed active prescriptions for Lexapro 10 mg daily for depression, haloperidol 1 mg daily for dyskinesia, trazodone 75 mg at bedtime for dyskinesias, and Klonopin 0.5 mg twice daily for anxiety. However, the clinical record lacked evidence of informed consent for any of these medications. During interviews, a licensed nurse stated she was unaware of the policy when a resident received psychotropic medication. An administrative nurse reported that she or another nurse completed psychotropic evaluations and notified families when new psychotropic medications were prescribed, and that a PA typically documented psychiatric medication management, but the PA did not see this resident because she used an outside provider. The administrative nurse further stated that the facility did not obtain a psychotropic consent for this resident because the off-site provider would obtain it, and no psychotropic consent documentation was present in the facility record despite a policy addressing antipsychotic medication use.
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