Failure to Obtain and Document Informed Consent for Psychotropic Medications
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents with cognitive and behavioral disturbances received IM Haldol for acute episodes of agitation, paranoia, and physical aggression after refusing PO medications and nonpharmacological interventions were ineffective. In both cases, providers ordered one-time IM Haldol doses on multiple occasions, and family members were notified of the orders and involved in communication about the residents’ behaviors and treatment. One resident’s family later filed a grievance regarding IM Haldol use, and informed consent was documented only for Trazodone. Facility leadership confirmed there was no documentation that the risks or side effects of Haldol were discussed with either resident or their responsible parties prior to administration.
A resident with multiple medical conditions, including metabolic encephalopathy and Generalized Anxiety Disorder, was started on BuSpar 10 mg BID following a psychiatric evaluation, but the responsible party was not properly informed of this new psychotropic medication order. Nursing notes lacked documentation of the psychiatrist’s assessment or any notification to the responsible party, even though the MAR showed the resident received two doses. The responsible party later reported learning of the medication only during an in-person visit and expressed concern due to the resident’s prior adverse reactions to psychotropic drugs. Conflicting accounts from two ADONs about when and how the responsible party was notified, combined with the absence of required documentation, demonstrated noncompliance with the facility’s policy on notifying and documenting changes in a resident’s condition or treatment.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, repeatedly requested to be transferred to the hospital during episodes of acute symptoms such as chest pain, low blood sugar, and gastrointestinal distress. Despite these requests, nursing staff deferred to the PCP, who typically ordered in-house treatment and monitoring rather than approving a hospital transfer. Staff interviews confirmed that the resident's right to self-determination and participation in care decisions was not honored, in violation of facility policy and resident rights regulations.
A resident with severe cognitive impairment sustained a skin tear during a mechanical lift transfer, but the responsible party was not notified of the incident or new wound care orders. Staff interviews revealed confusion about notification responsibilities, and the facility's policy requiring timely notification of the resident's representative was not followed.
A resident's court-appointed guardian was not notified about the initiation or charges for therapy services, nor was informed consent obtained for dental services after the resident switched to private pay. The resident, who had significant cognitive and medical issues, received multiple therapy and dental services without proper guardian notification or updated consent documentation.
A resident with a history of respiratory issues expressed concerns about having pneumonia and requested a chest x-ray, but the facility did not facilitate this due to the resident's body habitus and did not send him to the hospital. The resident was not examined by the physician during his stay, leading to dissatisfaction with the facility's handling of his health concerns. This situation highlights a failure to support the resident's right to self-determination in medical care.
Lack of Informed Consent for IM Haldol Use in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their responsible parties were informed of the risks of antipsychotic (Haldol) use prior to administration. For one resident with muscle wasting, difficulty walking, chronic venous hypertension with ulcers, CHF, and moderate cognitive impairment, behavior notes documented episodes of severe agitation, paranoia, physical and verbal aggression, refusal of oral medications, and rejection of care. In response, an NP ordered a one-time IM dose of Haldol, and later that same day a physician ordered a second one-time IM dose after the resident again became severely agitated and refused oral medications, including PRN Ativan. The resident’s son was notified of the orders and was present during some of the episodes, but there was no documentation that the risks of Haldol use were discussed with either the resident or her son. Subsequent documentation for this same resident showed continued severe paranoia, delusions, refusal of medications and care, and combative behavior, leading to additional IM Haldol administrations. Notes indicated that attempts had been made to initiate oral antipsychotic medication but were unsuccessful due to refusals, and that non-pharmacological interventions were not effective. The facility informed the family that there were no other interventions staff could initiate in the nursing setting and that the resident would benefit from transfer to a geriatric psych facility. Despite multiple Haldol injections and ongoing communication with the family about the resident’s condition and care needs, the corporate nurse later verified there was no documentation that the risks of Haldol had been discussed with the resident or her son. For a second resident with diagnoses including a left humerus fracture, metabolic encephalopathy, abnormal gait and mobility, history of falls, heart disease, and parkinsonism, the care plan identified risk for complications related to psychoactive medication use. The resident had intact cognition and required assistance with ADLs. Behavior notes documented episodes of paranoia, belligerence, attempts to crawl out of bed, physical aggression toward staff, refusal of PO medications, and belief of being held without permission, leading an NP to order IM Haldol on two separate occasions for safety after nonpharmacological measures were ineffective. A grievance was later filed by the family regarding the use of IM Haldol for an acute change in behavior, and an informed consent form for Trazodone was signed by the resident’s wife with potential side effects reviewed. However, there was no documentation that Haldol side effects or risks were discussed with the wife prior to either IM Haldol administration, and the corporate nurse confirmed the absence of such documentation.
Failure to Notify Responsible Party of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party was fully informed of and understood a change in the resident’s medication regimen. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur underwent an admission psychiatric evaluation by a consulting psychiatrist, who diagnosed Generalized Anxiety Disorder and ordered BuSpar 10 mg orally twice daily. The nursing progress notes for the period surrounding this evaluation contained no documentation of the psychiatrist’s assessment or of any notification to the resident’s responsible party about the new BuSpar order. The MAR showed the BuSpar order was entered and that the resident received two doses. The facility’s policy required immediate notification of the resident and authorized representative, with documentation in the medical record, when there was a change in the resident’s mental, physical, or psychosocial status. The resident’s responsible party reported that the facility started the resident on BuSpar and Trazodone for reasons unknown to her, and that she did not learn about the BuSpar until a nurse mentioned it during a visit. She stated the resident had previously experienced adverse reactions to psychotropic medications and that she did not want him on medications that cross the blood-brain barrier. One ADON stated she believed another ADON had notified the responsible party by phone and that she later met in person with the responsible party to discuss the BuSpar order, acknowledging the resident received two doses before discontinuation. The other ADON, however, stated she did not notify the family by phone, that all communication with the responsible party was in person, and that she discussed the BuSpar order with the responsible party at the next in-person visit and believed the resident did not receive any doses. There was no documentation in the medical record of timely notification to the responsible party about the initiation of BuSpar, contrary to facility policy.
Failure to Honor Resident's Right to Hospital Transfer
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding treatment options, specifically the right to request transfer to a hospital. The resident, who had a history of type II diabetes, hypertension, heart disease, schizophrenia, and other mental health conditions, was cognitively intact as evidenced by a BIMS score of 15. Multiple progress notes documented that the resident experienced various acute symptoms, including pallor, clamminess, twitching, incontinence, difficulty breathing, sweating, shaking, diarrhea, nausea, and chest pain radiating to the left arm. On several occasions, the resident explicitly requested to be transferred to the hospital due to these symptoms. Despite these requests, the nursing staff contacted the primary care provider (PCP), who typically ordered laboratory tests and monitoring rather than approving a hospital transfer. In some instances, the PCP did not return calls, and when contacted, often instructed staff to treat the resident in the facility, stating that hospital care would not differ from what could be provided on-site. The resident's care plan did not document repeated requests for hospital transfer, and staff interviews confirmed that the resident's wishes were not honored, with the PCP's refusal cited as the reason. The Social Services Director and the Interim Director of Nursing both acknowledged that the resident had the right to seek care elsewhere, and the Administrator stated that the resident should have been allowed to go to the hospital if requested. The facility's policy on resident rights, which includes self-determination and participation in care decisions, was not followed in these instances. Interviews with staff and the resident confirmed that the resident's repeated requests to be transferred to the hospital were not granted, and the staff deferred to the PCP's decision rather than honoring the resident's right to choose their treatment options. This resulted in a failure to comply with federal and state regulations regarding resident rights.
Failure to Notify Resident Representative of Incident and Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of an incident involving the resident, specifically a skin tear sustained during a mechanical lift transfer. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and cognitive communication deficit, was assessed as severely cognitively impaired. Documentation showed that the resident's son was listed as the responsible party and emergency contact. Despite this, there was no record that the son was informed of the skin tear or the subsequent new wound care orders. The son only learned of the injury days later during a visit, after inquiring about his father's comments regarding his foot. Staff interviews revealed confusion and inconsistency regarding notification responsibilities. The ADON stated she did not notify the family because she believed the resident was sometimes alert and oriented, and typically notified the resident directly. The DON admitted to not checking the responsible party information and assumed the resident was his own responsible party. Other staff confirmed the resident's cognitive status fluctuated, with orientation primarily to self and inconsistent recognition of others. Facility policy required notification of the resident's representative within 24 hours of any incident or change in condition, unless otherwise instructed by the resident, but this was not followed in this case.
Failure to Notify Guardian and Obtain Informed Consent for Therapy and Dental Services
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian about the initiation and potential charges for therapy services, as well as failed to obtain informed consent prior to starting dental services. Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, dementia, and malnutrition, was rarely or never understood and had a guardian appointed. Despite multiple therapy orders and treatments, there was no documentation that the guardian was informed of the therapy evaluations, treatments, or the associated charges. Billing statements confirmed that charges were incurred for occupational, speech, and physical therapy, but the guardian was not notified. Additionally, after the resident switched from Medicaid to private pay, there was no evidence that updated consent was obtained for dental services or that the guardian was notified of a dental visit. The previous ancillary consent form had been signed by the resident's wife for other services while the resident was on Medicaid, but no updated consent was documented after the change in payor status. The administrator confirmed that no updated informed consent was obtained and that billing for ancillary services was handled by the service providers, not the facility.
Failure to Support Resident's Self-Determination in Medical Care
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact, was fully informed and able to direct his own medical care. The resident, who had a history of pneumonia, acute respiratory failure, and other serious health conditions, expressed concerns about his respiratory status and requested a chest x-ray to confirm his condition. Despite his requests and the presence of symptoms such as a cough and fluctuating oxygen saturation levels, the facility did not facilitate a chest x-ray due to the resident's body habitus and did not send him to the hospital for further evaluation. The resident's progress notes indicated that he repeatedly expressed concerns about having pneumonia and requested medical interventions similar to those he received in a hospital setting. However, the facility's physician did not examine or communicate with the resident from the time of his admission until he was eventually sent to the hospital. The Director of Nursing confirmed that the physician did not order a chest x-ray and instructed the nurses not to send the resident to the hospital, despite the resident's persistent requests and concerns. Interviews with the resident and a family member revealed dissatisfaction with the facility's handling of the situation, particularly regarding the lack of a chest x-ray and the perceived lack of responsiveness to the resident's health concerns. The facility's policy on resident rights emphasizes the importance of supporting resident self-determination and choice in their healthcare, which was not upheld in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with resident rights.
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