Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of psychotropic medications. Record review showed multiple physician orders for Lorazepam, prescribed as needed every four hours for anxiety on several occasions, with each order later discontinued. Additional orders included Haldol 0.5 mg as needed for behavioral disturbances and Seroquel 25 mg twice daily for depression, both of which were also later discontinued. These medications were administered without corresponding, timely psychotropic medication consent forms signed by the resident or resident representative. Review of the resident’s Electronic Health Record revealed that a Psychoactive Medication Consent Form was completed only once, on 01/06/26, and only for Lorazepam. No other consent forms were found for the resident’s use of Seroquel, Haldol, or for the other periods of Lorazepam use. During an interview on 03/09/26 at 12:35 pm, the DON confirmed that psychoactive medication consent forms should have been completed prior to administering Lorazepam, Haldol, and Seroquel to this resident, but acknowledged that this did not occur. The report states that this deficient practice is likely to put residents at increased risk for undesirable side effects associated with these medications, including increased drowsiness, insomnia, fatigue, and sexual dysfunction.
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