F0552

D

Failure to Obtain Informed Consent Before Initiating Anti-Anxiety Medication

Bennington, Vermont Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident’s representative was fully informed and provided informed consent prior to the initiation of an anti-anxiety medication. Resident #2 was admitted on 5/27/2025 with physician orders for Depakote (anticonvulsant), Vistaril (antihistamine), and Zoloft (antidepressant) for a mood disorder, and there was no documented evidence that the resident’s representative was informed of the benefits, risks, or alternatives to these medications until a consent form was completed by the Unit Manager on 6/20/2025, indicating verbal consent from the responsible party. On 7/17/2025, a physician ordered Buspirone 10 mg by mouth twice daily for anxiety, and record review showed no documentation that the responsible party was informed of the benefits, risks, alternative treatments, or the initiation of this medication. A progress note dated 7/25/2025 documented that Buspirone was discontinued per provider and guardian request and that the responsible party was aware at that time, but in an interview the responsible party stated they had not been made aware when Buspirone was started and requested its discontinuation once informed. In a separate interview, the Director of Nursing confirmed there was no evidence that informed consent had been obtained from the resident’s representative prior to starting Buspirone.