Failure to Obtain Informed Consent for Psychotropic Medications: The facility lacked evidence that two residents or their representatives were informed about and consented to psychotropic meds, including buspirone, lorazepam, and Remeron. One resident could not recall her meds, and an LPN and admin nurse gave conflicting statements about whether psychoactive consents had been completed; the DPOA later said she had just signed the forms and that they were otherwise blank when signed.
Failure to Obtain Informed Consent for Psychotropic Medication: A resident receiving zolpidem for insomnia had EMR documentation showing the medication order and monitoring instructions, but no evidence of education or informed consent for the psychotropic/hypnotic medication. An LPN stated an admin nurse would complete psychotropic consents, and an admin nurse later confirmed she could not locate a consent for the medication.
A resident with dementia and severely impaired cognition received Ativan for anxiety related to dialysis, but the EMR lacked documentation of education or consent about the risks versus benefits of the psychotropic medication. Staff interviews showed confusion over who would complete the psychoactive consent, and an admin nurse later stated she completed the consent after the medication had already been ordered. The facility policy required a signed consent form for psychotropic medications.
Failure to Obtain Psychotropic Medication Consent: A resident with major depressive disorder and intact cognition was prescribed sertraline, but the EMR showed no indication that the resident or representative was informed of the medication’s risks, benefits, or side effects. The psychotropic medication consent was uncompleted and unsigned, and an RN stated the consent had been skipped over.
A resident with anxiety, insomnia, bipolar disorder, OCD, and severe cognitive impairment received multiple psychotropic medications, including antipsychotic, anti-anxiety, hypnotic, and antidepressant drugs. The EMR lacked evidence of informed consent that included the risks vs benefits and expected therapeutic benefit for these medications, and an Administrative Nurse confirmed the signed consent forms were missing.
A resident with anxiety, depressive disorder, and drug-induced dyskinesia, and with intact cognition per BIMS, was receiving multiple psychotropic medications, including an antidepressant, antianxiety, antipsychotic, and trazodone, without documented informed consent regarding risks and benefits. The care plan directed staff to educate the resident and family on psychotropic medication risks, benefits, and side effects, and assessments identified the medications as high risk with fall-related risk factors, yet the clinical record contained no consent documentation. Nursing staff reported being unaware of the psychotropic medication policy, and an administrative nurse stated that psychotropic evaluations and family notifications were usually done in-house, but in this case no psychotropic consent was obtained or documented because an outside provider managed the psychiatric medications.
A resident with dementia, anxiety, and depression had severely impaired cognition and was receiving multiple psychotropic medications, including an antipsychotic, an antianxiety medication, and an antidepressant. The EMR showed informed consent for some psychotropics, but not for trazodone. Staff stated consent was obtained for antipsychotics and that the facility should obtain consent for all psychotropic medications, but no policy for psychotropic consents was provided.
The facility failed to obtain complete and properly executed informed consents for psychotropic medications for multiple residents. Several residents were receiving antidepressants, antianxiety agents, and antipsychotics, yet their psychotropic consent forms were either missing signatures or did not list the specific medications, dosages, routes, or administration frequencies. Staff reported that informed consent was required before starting or changing psychotropic drugs and that consents were to be provided to residents or their representatives, and facility policy required signed consents at initiation and with dosage increases, but the documentation for these residents did not include the necessary medication details.
Facility staff failed to ensure informed consent and resident/representative education were documented for psychotropic meds for two residents. One resident had an increased olanzapine order without evidence of consent, and another had trazodone and citalopram orders without evidence of prior consent or education; staff interviews showed inconsistent understanding of when psychotropic consents were to be completed.
Failure to obtain updated psychotropic medication consent: A resident with depression, insomnia, anxiety, and chronic pain had intact cognition and was receiving antidepressant therapy and Lyrica for pain. The EHR showed a psychotropic consent for a lower Lyrica dose, but when the order was increased to TID, there was no evidence the resident or representative received education or informed consent for the dose/frequency change; an LN was unsure who completed consents, and an AN confirmed the consent was not accurate.
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