Failure to Obtain Informed Consent Before Initiating Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating a psychotropic medication for one resident reviewed for unnecessary medications. The resident, who had diagnoses including COPD, depression, and cardiomegaly, was ordered Aripiprazole 5 mg by mouth once daily on 11/27/25. Record review showed that the resident’s Psychoactive Medication Informed Consent form, which listed Aripiprazole 5 mg along with Bupropion 150 mg and Fluoxetine 40 mg, was not signed until 1/16/26, after the medication had already been started. In an interview, the CEO acknowledged that the resident should have signed a Psychotropic Medication Acknowledgement Consent prior to administration of Aripiprazole but had not done so.
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