Failure to Obtain Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain accurate informed consent for the use of the antipsychotic medication Zyprexa for a resident. The resident was admitted and later readmitted with diagnoses including Alzheimer's disease, dementia, and type 2 DM, and an MDS assessment showed moderately impaired cognitive skills and a need for assistance with activities of daily living. A Schizophrenia Diagnosis Checklist dated 2/12/2026 indicated the resident did not meet criteria for schizophrenia. However, the History & Physical dated 2/25/2026 documented a present illness of bipolar disorder and stated the resident did not have the capacity to understand and make decisions. On 2/25/2026, the physician's order directed Zyprexa 2.5 mg by mouth at bedtime for bipolar disorder manifested by screaming without cause. The facility’s consent form, also dated 2/25/2026, documented that the resident’s responsible party was made aware of and consented to Zyprexa 2.5 mg for a diagnosis of schizophrenia with the behavior of screaming without cause, rather than for bipolar disorder as written in the physician’s order. In an interview, the DON confirmed that the consent obtained was for schizophrenia and not for bipolar disorder, and stated it was important to obtain the correct consent so the resident and responsible party would know and be able to choose the appropriate treatment plan. The facility’s informed consent policy required that the attending physician disclose the reason for treatment and the nature and seriousness of the resident’s illness when obtaining informed consent for therapies including psychotherapeutic drugs.
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