Inaccurate Antipsychotic Consent Documentation
Penalty
Summary
The facility failed to maintain an accurate and updated medical record for one resident when the documented consent for an antipsychotic medication did not match the current physician order. The resident was admitted with diagnoses including Type 2 DM, major depressive disorder, anxiety, and dementia. A pharmacist’s Medication Regimen Review dated 11/26/25 noted that a consent could not be found for the resident’s Risperidone for the diagnosis of dementia with behavior disturbance and requested that the record be updated once consent was obtained. Review of the current consent for Risperidone, dated 08/26/24, showed it was completed for the diagnosis of schizophrenia. Further record review showed that the physician’s order dated 10/20/25 listed the indication for Risperidone as dementia, unspecified severity, without other behavioral disturbance, which did not match the diagnosis documented on the existing consent form. During an interview on 01/30/25, the MDS regional coordinator confirmed that the consent did not match the physician’s orders and acknowledged that the consent should be updated to reflect the current order. This discrepancy demonstrated that the facility did not ensure the resident’s medical record, specifically the consent for Risperidone, was accurate and consistent with the physician’s current orders.
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