F0552

E

Failure to Obtain Informed Consent for Psychotropic and Related Medications

Artesia, New Mexico Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to ensure residents and/or their representatives were informed in advance about medications and understood the reasons, risks, and benefits, as required for psychotropic medications. For one resident with an order for melatonin 9 mg at bedtime for insomnia, record review showed no consent form for the use of melatonin. During interview, the DON confirmed that staff did not obtain the required psychotropic medication consent form prior to the resident starting melatonin, despite the expectation that such forms be completed before initiating psychotropic medications.

For a second resident with orders for melatonin 5 mg daily for insomnia and alprazolam 1 mg three times daily for anxiety/restlessness, record review revealed no consent forms for either medication, and the DON confirmed consents were not obtained prior to use. For a third resident with orders for melatonin at bedtime for insomnia, olanzapine in the morning and at bedtime for schizophrenia, and gabapentin three times daily for pain/bipolar disorder, there were no consent forms in the medical record for any of these medications. The DON verified that staff did not obtain the required psychotropic medication consent forms before these medications were started, contrary to facility expectations.