Failure to Obtain Informed Consent Before Administering Psychoactive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed in advance and that consent was obtained prior to administering a psychoactive medication. Resident #1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination. An admission MDS assessment documented that the resident was moderately cognitively impaired, required moderate assistance with most ADLs, and received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for insomnia, unspecified. Record review showed that the informed consent for psychoactive medication form for Trazodone was signed by Resident #1’s legal representative on 03/10/26, and the section indicating whether the representative consented to the medication was not completed. The medication had already been administered to the resident on 03/09/26, before the consent form was signed and completed. During an interview, the DON acknowledged that the informed consents for Trazodone were not completed and did not show if the medication was consented to by the responsible party, and stated that informed consents should have been completed prior to administering the medication. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission, the admitting nurse will review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information obtained in the clinical record.
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