Lack of Informed Consent and Appropriate Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to provide an explanation of the risks and benefits of psychotropic medication use and obtain consent prior to administering a psychotropic medication to one resident. Facility policy on psychotropic medication use, revised February 2025, stated that residents who had not used psychotropic medications were not to be prescribed or given these medications unless necessary to treat a specific, diagnosed, and documented condition. Resident 9’s clinical record showed diagnoses of major depressive disorder and dementia, and a physician’s order for Depakote 250 mg by mouth at bedtime for mood beginning on September 12, 2025. The resident’s care plan included a focus that the resident used antidepressant and mood stabilizer medication related to depression, last revised on September 21, 2025. However, during an interview on February 11, 2026, at 11:45 AM, the Director of Nursing stated that Resident 9 did not have an appropriate diagnosis for Depakote documented in the medical record, indicating the medication was used without the required documented diagnosis and without documented explanation of risks and benefits and consent. This deficiency was cited under 211.12(d)(1)(3)(5) Nursing services.
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