Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, prior to administering psychotropic medications to a resident. Facility policy NSG206 Behaviors; Management of Symptoms, revised September 25, 2025, required staff to obtain consent when medication is ordered for behavioral symptoms. Resident 4 had diagnoses including major depressive disorder and dementia, and physician orders showed Zoloft 25 mg by mouth at bedtime for depression starting January 29, 2026, and Olanzapine 5 mg at bedtime for psychotic behaviors starting December 21, 2025. The resident’s care plan identified a focus that the resident was at risk for complications related to the use of psychotropic drugs, created on December 22, 2025. Review of the resident’s medical record did not reveal any documentation of an explanation of the risks and benefits of these psychotropic medications or consent for their use by the resident or their representative. In an interview, the Director of Nursing confirmed that the appropriate notifications were not made prior to starting the psychotropic medications for this resident. This deficiency was cited under 211.12(d)(1)(3)(5) Nursing services.
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