F0552

D

Failure to Obtain Representative Consent for Psychotropics and Notify Guardians of Offsite Appointments

Grand Rapids, Michigan Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly inform and obtain consent from resident representatives for care and treatment, including psychotropic medications and offsite medical appointments, for two residents. One resident with schizoaffective disorder, bipolar type, had documentation indicating moderate cognitive impairment and an inability to process and understand medical information or make informed medical treatment decisions. A probate court physician report and a Determination of Inability to Participate in Complex Decision Making form, signed by two physicians, stated that this resident was not able to make or participate in medical treatment decisions. Despite this, psychotropic medication consent forms for an antipsychotic (Perphenazine) and an antianxiety medication (Alprazolam) documented that education was provided to and consent was obtained from the resident himself.

The facility’s own Psychotropic Medication Use policy required that consent for each psychotropic medication be obtained from the resident or authorized representative, with education on risks versus benefits. Social Services staff confirmed that when a resident is deemed unable to make medical decisions, informed consent must be obtained from the legal guardian or authorized representative. They further confirmed that this resident could not make medical decisions, did not yet have a legal guardian when Alprazolam and Perphenazine were initially prescribed, and that the authorized resident representative did not provide consent for these medications. As a result, the resident received psychotropic medications without consent from the appropriate representative, contrary to the facility’s policy and the documented incapacity determinations.

The second resident had paranoid schizophrenia and a cognitive communication deficit and had two co-guardians appointed by court order. A family member co-guardian reported that she and her sister had always made the resident’s medical treatment decisions and routinely attended all medical appointments, including those with a local mental health authority that managed the resident’s monthly Haldol injections. The co-guardian stated that the facility sent the resident to an outside medical appointment with a staff member on one occasion and to a mental health authority appointment alone on another occasion, without notifying either co-guardian. The mental health authority nurse confirmed that it was unusual for the resident to attend without the co-guardian, who had historically been present and served as a resource and advocate.

The unit clerk, who was responsible for scheduling outside medical appointments, reported that when a resident has a guardian, she is supposed to ensure the guardian is aware of outside appointments and that, if the guardian cannot attend, the facility would send a staff member. She stated she scheduled one of the resident’s appointments and attempted to notify the co-guardian by preparing a written slip with appointment information. She said she waited to hand it to the co-guardian but, not wanting to interrupt a conversation, instead placed the slip on the resident’s meal tray in the room. The unit clerk gave inconsistent accounts about whether she later spoke with the co-guardian by phone and could not recall the date or details of any such conversation. She was unable to provide documentation verifying that the co-guardian had been informed of the appointment. As a result, the resident attended at least one offsite appointment without representation from her co-guardian, despite the facility’s awareness that the co-guardian expected to be notified and typically accompanied the resident.