Failure to Obtain and Document Informed Consent for Psychotropic Medication Use and Changes
Penalty
Summary
Surveyors found that the facility failed to ensure residents or their representatives were informed of the benefits and risks of certain psychotropic and antianxiety medications, and failed to document informed consent. One resident lacked capacity to make medical decisions and had a diagnosis of unspecified dementia with agitation. The physician ordered multiple medications for this condition, including lorazepam (for use prior to showers and for agitation), Rexulti, and Seroquel. Review of the Medication Administration Record showed these medications were administered as prescribed. However, review of progress notes and other documents revealed no evidence that the resident’s representative had been informed of the benefits and risks of these medications prior to their use, and no signed informed consent forms were found in the electronic health record. Medical Records staff reported being unable to locate any such consents. For another resident who also lacked capacity to make medical decisions, the physician changed the dosage of Seroquel on a specified date. Record review showed no evidence that the resident’s MPOA was notified of this change in medication dosage and treatment. During an interview, the DON stated that nurses should always notify the resident or power of attorney of any changes to care or medications and acknowledged that staff “must have missed this one.” These findings were identified during review of five records under the unnecessary drug pathway, with two residents affected.
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