F0552

D

Failure to Obtain Informed Consent for Psychotropic Medications

Pasadena, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to obtain informed consent from a resident’s court-appointed conservator prior to initiating three psychotropic medications. The resident had diagnoses including anxiety disorder, depression, and schizoaffective disorder and was readmitted to the facility with these conditions. The physician ordered Paliperidone ER 6 mg twice daily for schizoaffective disorder, Haldol 5 mg IM every eight hours as needed for schizoaffective disorder, and Buspirone 30 mg twice daily for anxiety disorder. The Minimum Data Set indicated the resident had intact cognitive skills for daily decision-making and required varying levels of assistance with activities of daily living. The Medication Administration Record showed that Paliperidone and Buspirone were administered on multiple occasions and Haldol was administered once.

During interviews, an LVN stated that the resident’s three psychotropic medications should have had complete informed consent before administration and that the conservator should have been informed of the risks and benefits and asked for consent. In a concurrent record review and interview, the DON confirmed that there was no signed informed consent in the resident’s record and acknowledged that an informed consent signed by the conservator was required for the use of psychotropic medications to inform the resident or conservator of the reason for treatment, the nature and seriousness of the illness, and to provide a choice to approve or decline the medications. Review of the facility’s Informed Consent policy, revised January 16, 2025, showed that when initiating a new order or increasing psychotropic drugs, the attending physician must obtain informed consent from the resident or responsible party. Despite this policy, informed consent was not obtained before the psychotropic medications were administered.