Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were fully informed about and consented to psychotropic medication treatment. For one resident admitted with multiple complex conditions including acute and chronic respiratory failure, diabetes with chronic kidney disease, dysphagia and hemiplegia following cerebral infarction, secondary malignant neoplasm of the large intestine and rectum, peripheral vascular disease, ischemic cardiomyopathy, and hypertension, the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment with daily decision-making ability. This resident was receiving the psychotropic medication Zoloft 25 mg daily via PEG tube for major depressive disorder, initiated by physician order on 12/08/2025 and administered daily in January 2026 as documented on the MAR. On 02/11/2026, an LPN confirmed there was no documentation in the medical record to support that consent for Zoloft had been obtained. The facility also failed to obtain documented consent for psychotropic medication for another resident admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris, bipolar disorder, hyperlipidemia, and anemia. The annual MDS showed a BIMS score of 6, indicating severe cognitive impairment with daily decision-making. This resident was receiving Abilify 2.5 mg by mouth daily for bipolar disorder, initiated by physician order on 07/21/2025 and administered daily in January 2026, except during hospitalization, as shown on the MAR. On 02/11/2026, an RN confirmed there was no documentation in the medical record to support that consent for Abilify had been obtained. These findings show the facility did not address the residents’ right to be informed in advance of the risks and benefits of psychotropic medication treatment and to provide consent.
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