Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident’s responsible party (RP) prior to initiating and administering a psychotropic medication. The resident, who had diagnoses including unspecified intellectual disabilities, was seen by a mental health nurse practitioner on 2/27/26, and an order was written to start buspirone twice daily for anxiety disorder. Nursing documentation indicated that the orders were noted and carried out, and the medication was added to and administered per the Medication Administration Record (MAR). Review of the electronic health record showed no documentation that informed consent for the psychotropic medication had been obtained from the resident’s RP before the medication was started. The MAR showed that buspirone was administered on multiple occasions, including doses on 2/28/26 and several dates in early March, totaling seven doses. During interviews, a licensed nurse confirmed that informed consent was required before administering buspirone due to the nature of the medication and its potential side effects, and acknowledged that consent had not been obtained from the RP prior to administration. The nurse further stated that when the facility did contact the RP, the RP stated they did not want the resident to receive the medication. The Director of Staff Development stated that facility practice required informed consent from the resident or RP before adding a psychotropic medication to the MAR, and facility policies on Resident Rights and Psychotropic Medication Use indicated that residents and their representatives must be informed of and participate in treatment decisions and that written informed consent must be obtained for psychotherapeutic drugs.
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