Failure to Document Informed Consent for Restraints and Psychotropic Medications: The facility did not show that residents or their representatives were informed of the risks, benefits, and alternatives before restraints were started for two residents or before psychotropic meds were started for four residents. Records showed general restraint consents, wheelchair seatbelts/alarms, and multiple psychotropic orders, but the charts lacked documentation of specific consent discussions. Interviews with the DON and an LPN showed staff were unaware of informed consent requirements for psychotropic meds, despite facility policy requiring review of alternatives, rationale, risks/benefits, and the right to accept or decline treatment.
A resident with depression, dementia, and anxiety disorder was started on lorazepam PRN for anxiety, but the record had no documentation that the resident or representative was informed in advance of the medication’s risks, benefits, or alternatives, or that consent was obtained. The DON stated psychotropic meds require informed consent prior to administration, including on admission, and nursing staff are responsible for obtaining it.
Failure to inform a resident’s representative about psychotropic meds: A resident with anxiety disorder, bipolar disorder, and severe cognitive impairment was ordered aripiprazole, buspirone, and paroxetine via feeding tube, but the EMR lacked documentation that the benefits, risks, and alternatives were explained. The family member said they were not informed of the medication changes, and facility leadership confirmed the information had not been provided.
A resident with bipolar disorder, depression, anxiety, and OCD, and intact cognition, received multiple psychotropic medications including an antidepressant, antipsychotic, and anti-anxiety agents. The record contained no documentation of informed consent for any of the psychotropic medications, and the RN UM confirmed the consent could not be found; the DON stated informed consent was expected before administration.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents received psychotropic medications for depression disorder without documentation that the resident or representative was informed in advance of the risks, benefits, or alternative treatment. One resident had moderately impaired cognition and the other had severe cognitive impairment; EMR review found no signed informed consent for Bupropion, Effexor, Sertraline, or Trazodone. Staff interviews showed uncertainty about who was responsible for obtaining consent.
Failure to Document Informed Consent for Psychotropic Medications: The facility did not document that two residents were informed of the risks, benefits, and alternatives before psychotropic meds were started or increased. One resident with depression and insomnia received eszopiclone and hydroxyzine, and another resident with depression and pseudobulbar affect had an order for hydroxyzine PRN for anxiety; the records contained no consent documentation. The DON confirmed consent forms could not be located, and the pharmacist confirmed hydroxyzine is a psychotropic when used for anxiety.
Failure to obtain consent for psychotropic medications: The facility had no signed consent in the EMR for two residents receiving psychotropic meds. One resident had severe cognitive impairment with diagnoses including Alzheimer’s disease, schizophrenia, psychosis, depression, and anxiety, and active orders for clonazepam, quetiapine, and escitalopram. The other resident had moderate cognitive impairment with dementia, psychotic disturbance, mood disturbance, and anxiety, and active orders for lorazepam, quetiapine, and escitalopram. The RP for one resident did not recall signing consent, and the DON acknowledged the missing consents.
Failure to obtain informed consent for psychotropic medication: A resident with vascular dementia, seizures, and moderate cognitive impairment received quetiapine for behavior management before proper consent was obtained. The resident stated they did not know what the medication was for and signed the form only after being told it would be given for a couple more days. Staff interviews showed confusion over who was responsible for obtaining psychotropic medication consents, and the DON and Administrator stated consent should be obtained before the medication is administered.
A resident's insurance provider was changed to Medicare without notifying or obtaining consent from the legal guardian, despite facility policy requiring such notification and documentation. The responsible party was not consulted or informed prior to the change, and this was confirmed by the Business Office Manager.
Two residents were administered psychotropic medications without being informed of the risks and benefits, as required by facility policy. Consent forms were signed by representatives prior to admission but did not include specific information about medication risks and benefits. Facility staff confirmed that education on these medications was not documented or provided prior to administration.
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