Lack of Documented Risk/Benefit Education and Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide education on the risks and benefits of psychotropic medications and to obtain consent prior to administration, as required by facility policy. The policy on psychotropic drugs, revised June 6, 2019, states that when an antipsychotic is ordered, the resident and/or responsible party will be educated on the risks versus benefits of taking the medication. For one resident with diagnoses including delusional disorder, vascular dementia, depression, and anxiety, physician orders included Haldol in multiple doses and Trazodone. A psychology consult documented that Haldol had been started after a failed gradual dose reduction of Geodon. A progress note from November 3, 2025, stated that antipsychotic risks versus benefits were reviewed with the responsible party, but it did not identify the specific medication discussed. A November 4, 2025, note indicated the resident was admitted with orders to decrease Geodon and start Haldol and that a letter was sent to the responsible party with a copy of the risks versus benefits of antipsychotic medications. A January 20, 2026, note documented initiation of Trazodone for continued signs of distress and that a message was left for the responsible party, without documentation of completed education or consent. For another resident with delusional disorder and dementia, physician orders included Risperidone 1 mg by mouth three times daily, and the care plan identified behavioral problems due to vascular dementia with psychotic features and the possible need for antipsychotic medication. Review of this resident’s medical record did not reveal any documented education on the risks and benefits of Risperidone or any consent from the resident or their representative. During an interview, the Nursing Home Administrator stated they could not provide any documented consent for this resident’s Risperidone use. The DON also stated that the facility should obtain consent and discuss risks and benefits for antipsychotic medication use with the resident or representative prior to administration. These findings were cited under 28 Pa. Code: 211.10(a) Resident care policies and 211.12(d)(1)(5) Nursing services.
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.