Failure to Obtain Representative Consent for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent from a resident’s representative before initiating an antipsychotic medication. The resident was admitted in October 2025 with dementia with psychotic disturbance and was assessed on 10/29/25 with a BIMS score of 6/15, indicating severe cognitive impairment. On 12/23/25, a physician (Staff #16) ordered Seroquel 25 mg twice daily, and on 12/26/25 documented that the resident was agitated, not tolerating nursing or therapy care, and that a short course of Seroquel would be started for mood stabilization. Review of the resident’s paper and electronic medical record showed no documentation that consent was obtained from the resident’s representative for the administration of Seroquel. Medication Administration Records showed that the resident began receiving Seroquel on 12/23/25 at 9:00 PM and continued to receive it twice daily through 1/27/26, when the medication was placed on hold for seven days. The February 2026 MAR showed that Seroquel 25 mg was restarted on 2/4/26 at 9:00 AM and continued until 2/6/26 at 9:00 AM. During interviews, Staff #16 confirmed that facility staff failed to obtain consent for the administration of Seroquel, and the Director of Nursing confirmed that staff failed to obtain consent from the resident’s representative for this change in treatment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.