Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
Guardian Not Informed of Antipsychotic Dose Increase: A resident with schizophrenia and dementia had Haldol increased from 1 mg BID to 2 mg AM and 3 mg HS, but the record lacked documentation that the court-appointed guardian was informed or that guardian consent was obtained for the psychotropic dose change. The DON stated the guardian should have been notified and signed the consent, while the consent form in the record was signed by the resident.
A resident with Alzheimer’s disease, dementia, and anxiety was started on Valium and later buspirone for anxiety, agitation, and irritability, with multiple changes in dosing and frequency, without any signed informed consent documented in the clinical record. The resident’s spouse reported she was not asked to sign an informed consent and only received information about the medication from the pharmacy when picking it up. The Social Service Director stated that informed consents were required for all psychotropic medications but did not recognize buspirone as requiring consent due to the absence of a black box icon in their system and relied on nursing staff to notify her of dose changes. Despite a facility policy requiring documentation of discussions about risks and benefits of psychoactive medications, no such documentation or signed consents were present for these medications.
A resident with bipolar disorder, anxiety, and mild cognitive impairment, documented as cognitively intact and independent with ADLs, was transferred under an Emergency Detention Order to a psychiatric facility after refusing to go and being escorted by police. Facility staff reported to the psychiatric facility that the resident had recent physical and verbal aggression, including cursing at a roommate and spraying a staff member with chemicals, but these behaviors and alleged medication refusals were not supported by nursing documentation in the clinical record and were based on secondhand reports from social services. The DON later stated the resident had not shown aggressive behaviors, there was no documented medication refusal, and she was unsure why the resident was sent to a psychiatric hospital, while the resident reported she did not understand why she was transferred and that the reason was never explained to her, demonstrating a failure to ensure the resident was fully informed of and able to choose her treatment.
The facility failed to keep residents and their representatives informed about key aspects of care and treatment. A resident with a recent above-knee amputation and chronic pain had a prescribed narcotic pain medication dose reduced without being informed, only discovering the change when the medication appeared different, and there was no documentation of notification in the record. The same resident had a hospital-ordered vascular follow-up appointment for suture management that was missed, with no documented effort by the facility to notify the resident of the appointment or to reschedule after a no call/no show. In a separate case, another resident with dementia was discharged from therapy after about a month when max potential was deemed reached, but the PT did not notify the family and relied on nursing staff, and the record contained no documentation that the resident’s representative was informed of the discontinuation of therapy.
A resident with hemiplegia, kidney stones, urine retention, and ureteral stents reported back pain and asked to go to the ER, but the nurse contacted the on-call provider and the resident was not sent out at that time. The resident was given acetaminophen while waiting for PRN oxycodone to become available. Later that day, the resident became unable to answer questions correctly, had abnormal vital signs, and was sent to the ER after the NP was contacted; hospital records later showed sepsis, acute encephalopathy, and pseudomonas aeruginosa in the urine.
A resident with dementia and multiple comorbidities remained on a full liquid diet carried over from a hospital stay, even though the liquid diet had been ordered for nutritional reasons rather than swallowing issues and the resident was observed eating without difficulty. The resident’s POA and family repeatedly requested a change to a soft/mechanical diet, reporting they had safely fed the resident soft foods such as mashed potatoes and cottage cheese, but facility staff stated they would not change the order and discussed requiring a legal waiver if the family fed foods outside the ordered diet. Therapy and nursing leadership indicated that, because the resident could not follow commands, they believed she did not meet criteria for a diet change and did not ensure a timely, thorough swallow evaluation, resulting in the facility not honoring the resident representative’s diet preferences despite a policy supporting resident self-determination.
The facility failed to obtain informed consent for psychotropic medication use for multiple residents. Residents with diagnoses including depression, dementia, anxiety, schizoaffective disorder, PTSD, psychotic disorder, and bipolar disorder were receiving antidepressants, antianxiety meds, antipsychotics, and a hypnotic, but consent notifications and signatures were not obtained until after the survey team requested the documentation.
A resident with COPD, heart failure, dementia, and other conditions, who was on oxygen therapy, developed a cough and later received a new order for albuterol nebulizer treatments twice daily for the cough. The medical record lacked documentation that the resident’s representative was informed of this change in condition and new medication order. In interview, an LPN confirmed she did not document any communication with the representative, and the DON stated that such communication and documentation should have occurred.
A facility failed to obtain informed consent before increasing psychotropic meds for two residents. One resident with MDD, GAD, and Alzheimer’s disease had Zoloft increased, and another resident with schizophrenia, vascular dementia, and bipolar disorder had Clozaril increased. The clinical records lacked documentation that the residents and/or their representatives were informed of the treatment options, risks, and benefits before the dose increases, and the DON confirmed consent had not been obtained.
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