Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
Surveyors identified a deficiency related to the use of a psychotropic medication without proper informed consent. Resident #1, admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination, had an admission MDS showing moderate cognitive impairment and a need for moderate assistance with most ADLs. The MDS also reflected that the resident 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 unspecified insomnia. Record review showed that the informed consent for psychoactive medication for Trazodone was signed by the resident’s legal representative on 03/10/26, and the form indicated that the legal representative did not consent to the medication. Despite this, Trazodone had already been administered to the resident on 03/09/26, prior to obtaining a signed consent. During an interview, the DON acknowledged that medication was not supposed to be given without a consent form because it could cause an adverse effect to the resident. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission the admitting nurse would review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information in the clinical record, but this process did not prevent administration of Trazodone before consent was obtained.
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