A facility failed to document informed consent for psychotropic medications for three residents. One resident with severe dementia was receiving an antipsychotic, one resident with moderate cognitive impairment and multiple diagnoses was receiving PRN lorazepam, and one cognitively intact resident was receiving sertraline for anxiety. The records lacked documentation that the residents or their representatives were informed of the risks and benefits, treatment alternatives, or other options, and the DON confirmed the missing consent documentation while the Administrator stated there was no policy or procedure for psychotropic medication consents.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not ensure residents and/or representatives were informed of the risks, benefits, and side effects of psychotropic meds before administration for three sampled residents. One resident had severe cognitive impairment and was prescribed multiple antipsychotic and antidepressant meds, another had severe cognitive impairment with numerous psychotropic orders, and a cognitively intact resident stated he never signed consents and had not really been spoken to about his psychotropic meds. The clinical records lacked signed consent forms, despite the facility policy requiring education on psychotropic drug use and alternatives.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility lacked documentation that residents or their representatives were informed of the risks, benefits, and alternatives for psychotropic meds for multiple residents. Several residents had dementia or severe cognitive impairment, while one had intact cognition, and were prescribed meds such as lorazepam, aripiprazole, duloxetine, quetiapine, trazodone, risperidone, and amitriptyline. Staff and the DON stated consents were not obtained in some cases because the meds were started before admission, were home meds, or were missed during an EHR transition.
A resident with non-Alzheimer's dementia and mood disorder was receiving multiple psychotropic medications, including an antipsychotic and antidepressants, but the facility could not provide consent forms showing the resident or representative was informed about the risks, benefits, and alternatives. The only consent form available was signed for another resident, and the facility policy required collaboration with the resident or representative and information about the medication regimen's risks and benefits.
Missing informed consent for psychotropic medications: The facility did not document informed consent before giving psychotropic meds to 5 reviewed residents. Records showed residents receiving antipsychotic, antianxiety, and antidepressant medications, including residents with intact cognition and one resident with severe cognitive impairment. The DON could not find consent documentation in the EHR, staff described education as being documented in progress notes, and the facility policies did not direct nursing staff to provide education on treatment options, benefits, and risks.
Failure to inform residents about psychotropic meds: The facility did not document consent, education on risks/benefits, or discussion of alternative tx before starting or increasing psychotropic medications for several residents. Records showed orders for antidepressants, antianxiety meds, antipsychotics, hypnotics, and related dose changes, but no progress notes or assessments confirmed that residents or their representatives were informed in advance as required by facility policy.
Psychotropic consent forms were incomplete for 3 residents receiving antianxiety, antidepressant, and antipsychotic medications. The forms documented medication education and side effects, but did not consistently identify the target behaviors or non-pharmacological interventions attempted. Staff, including the Social Services Coordinator, MDS Coordinator, and DON, acknowledged the forms were not completed in full as required by policy.
Failure to obtain consent and provide psychotropic medication education: A resident with late onset Alzheimer’s Disease was started on multiple psychotropic meds, including an antidepressant, antipsychotic, antianxiety med, and another antidepressant, but the EHR did not show consent before initial administration. There were also no progress notes or assessments documenting education on side effects, risks vs benefits, or offering alternative treatments before the meds were given, despite facility policy requiring informed consent and discussion of nonpharmacological approaches and medication alternatives.
Failure to Document Consent and Education for Psychotropic Medications: The facility did not document consent, resident education, or discussion of alternative treatments before giving psychotropic medications to four residents with diagnoses including dementia, anxiety, depression, PTSD, insomnia, and bipolar disorder. Records showed orders for antidepressants, antianxiety medications, antipsychotics, and hypnotic agents, but no progress notes or assessments reflected education on risks and benefits or that alternatives were offered, and the facility had no policy for psychotropic medication use.
Failure to inform a resident representative of the risks and benefits and treatment alternatives before starting sertraline for a resident with dementia, depression, and severely impaired cognition. The EHR lacked documentation of advance notification or consent, the MAR showed daily administration of the SSRI, and both the Administrator and family representative confirmed no prior family consent or notification occurred.
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