Failure to Obtain Informed Consent Before Initiating Antidepressant Medications
Penalty
Summary
The facility failed to obtain informed consent prior to initiating psychotropic (antidepressant) medications for two residents reviewed for unnecessary medications. The facility’s Medication Therapy policy required that each resident’s medication regimen include only necessary medications and that medication use be consistent with the individual’s condition, prognosis, values, wishes, and responses to treatment. Resident #1, admitted and later readmitted with multiple diagnoses including heart failure and anxiety, had a physician order dated 3/1/26 for Citalopram Hydrobromide 20 mg by mouth once daily, but the Resident Nurse Coordinator (RNC) confirmed on 4/13/26 that there was no signed Informed Consent for Use of Antidepressant Medications for this order. Resident #35, admitted and later readmitted with multiple diagnoses including a stable lumbar vertebra fracture, depression, and repeated falls, had a physician order dated 4/1/26 for Sertraline HCl 200 mg by mouth at bedtime; the medical record contained an informed consent for use of antidepressant medication signed and dated 4/10/26, and on 4/13/26 the RNC stated that this informed consent should have been signed before the resident received the medication but was not.
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