Failure to Inform Resident of Risks and Benefits of Psychotropic Medication
Penalty
Summary
Surveyors found that the facility failed to ensure a resident was informed in advance of the risks and benefits of a prescribed psychotropic medication. The facility’s Health Care Decision Making policy, reviewed June 12, 2025, states that all patients/residents have the right to participate in their own healthcare, including consent, refusal, or withdrawal of consent for treatments and services. Clinical record review for Resident 3, who had diagnoses including hypertension and depression, showed a physician’s order for Zoloft 50 mg by mouth once daily for depression, initiated on December 5, 2025. Review of the facility’s Psychotropic Medication Administration Disclosure form, which is intended to ensure residents are fully informed about psychotropic medications, revealed that neither the resident nor the resident’s representative was informed of the risks and/or benefits of Zoloft, and the disclosure form was not signed. In an interview, the DON confirmed that the disclosure form was not signed and that the medication was not reviewed with the resident when it was ordered by the physician, resulting in noncompliance with 28 Pa. Code 211.12(d)(5) Nursing services.
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