Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their representatives of the risks and benefits of psychotropic medications and did not obtain consent prior to administering these medications for three residents reviewed. The facility’s Psychoactive Medication Policy, last reviewed on April 30, 2025, did not contain any expectation for obtaining consent before starting psychoactive medications. For one resident with major depressive disorder and dementia, physician orders showed Trazodone 75 mg three times daily for depression starting February 13, 2026, and Lorazepam 0.5 mg twice daily for anxiety starting December 16, 2025. The care plan documented psychotropic drug use beginning July 9, 2024, but the medical record contained no documentation of an explanation of risks and benefits or consent for these medications. The DON confirmed that appropriate notifications were not made prior to starting psychotropic medications for this resident. Another resident with dementia and depression had multiple psychotropic medication orders, including quetiapine, Rexulti, mirtazapine, and trazodone, with corresponding care plan focuses on antipsychotic and antidepressant use. However, the medical record lacked documentation of any explanation of the risks and benefits of these psychotropic medications or consent from the resident or representative, and the DON and Regional Director of Clinical Services stated there were no psychotropic medication consents for this resident. A third resident with bipolar disorder, anxiety disorder, depression, and dementia had orders for aripiprazole, bupropion, and escitalopram, and a care plan focus on psychotropic drug use including antidepressant, antipsychotic, and mood stabilizer medications. Review of this resident’s record also failed to show any explanation of risks and benefits or consent for psychotropic medication use, and staff confirmed that no psychotropic medication consents were available. These findings were cited under 28 Pa. Code 201.29(a) Resident rights and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
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