F0552

D

Failure to Obtain Informed Consent for Initiation of Psychotropic Medication

Boone, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and document informed consent for the initiation of a psychotropic medication. A resident with Lewy Body Dementia and severe cognitive impairment, as documented on the admission MDS, had no behavioral symptoms and was receiving antidepressant medications during the assessment look-back period. The December 2025 MAR showed a physician order dated 12/04/25 for risperidone 0.5 mg twice daily for a mood disorder. Review of the resident’s electronic medical record revealed no documentation that the resident’s Responsible Party was informed in advance of the risks and benefits of starting risperidone or that consent to this treatment was obtained.

Staff interviews further clarified the breakdown in the facility’s process for obtaining informed consent for psychotropic medications. The Social Worker and Social Worker Assistant, both of whom started in August 2025, reported they were not responsible for obtaining informed consents and stated that the NP was responsible for this task. The NP reported that he had previously been given forms to sign monthly by the former Social Worker, but that this practice stopped when the former Social Worker left, and he acknowledged he was not obtaining informed consents before initiating psychotropic medications, instead only reviewing medications generally during rounds and documenting in progress notes. The DON explained that the prior system relied on the Social Worker to notify the NP when informed consent was needed for new psychotropic medications and stated that this system failed when the last Social Worker left, resulting in the lack of informed consent for the psychotropic medication initiated for this resident.