Failure to obtain informed consent for psychotropic medications affected two residents. One resident with advanced cognitive impairment and another resident with moderately impaired cognition were prescribed multiple psychotropic drugs, including antianxiety, antipsychotic, antidepressant, and hypnotic agents, but their charts contained no consent forms or documentation showing that the residents or their representatives were informed of the risks, benefits, and alternatives. The DON and DSS acknowledged missing consents and stated the facility had previously limited forms to antipsychotics or could not locate the documentation.
Missing Informed Consent for Psychotropic Medication Change: A resident with Alzheimer’s dementia, severe cognitive impairment, psychosis, and behavioral symptoms was switched from Ativan to Xanax for shower days, but the chart contained informed consent only for Ativan and none for Xanax. The SW reviewed the record and confirmed the consent for the new psychotropic medication was missing.
Informed consent was not obtained before starting a resident on a psychotropic medication. The resident was cognitively intact, had anxiety and depression, and was receiving Buspar, Lamictal, and Lexapro, but the consent form only covered some of the psychotropic meds and did not include Lexapro. The SS RN and Administrator both confirmed consent should have been obtained before the medication was started.
Failure to Obtain Proper Psychotropic Medication Consent: A severely cognitively impaired resident with Alzheimer's Disease, depression, and anxiety was prescribed Seroquel, Buspirone, and Sertraline, but the psychotropic consent in the record showed the resident was educated and consented instead of the son listed as MPOA. The resident was unable to participate meaningfully due to cognition, and the facility policy required informed consent from the resident and/or authorized representative with review of risks, benefits, side effects, and Black Box Warnings.
The facility failed to obtain informed consent from the appropriate responsible party before starting an antipsychotic medication for a resident admitted with encephalopathy, traumatic brain injury, and mild neurocognitive disorder. Although a DPOAH had been activated and the admission note documented that the resident was incapable of making informed decisions, staff obtained verbal consent for Seroquel directly from the resident and initiated two daily dosing orders. The resident’s representative later reported she had not approved the drug and would never have consented to it, and an IDT note recorded the family’s concern about the resident being sedated and on Seroquel. The SSD, responsible for medication consent forms, stated that the responsible decision-maker should sign consents and suggested the failure to obtain consent from the DPOAH was likely a clerical error, despite facility policy requiring informed consent from the resident and/or responsible party for psychotropic medications.
Failure to obtain informed consent for psychotropic meds: two residents received antipsychotic/antidepressant therapy without documented consent for the current order or dose/form change. One resident with bipolar disorder and anxiety had a switch from IM risperidone to oral Risperdal without a new consent, and another resident with MS and depression had venlafaxine ordered without a consent found in the EMR; the SSD also could not locate one.
Failure to obtain informed consent for psychoactive medications. A resident with severe vascular dementia and severely impaired cognition was prescribed quetiapine, an antipsychotic, and sertraline, an antidepressant, but the record showed no written or verbal consent from the responsible party and no documentation that side effects or adverse reactions were explained. The DON stated there was no consent for those meds.
Incomplete Psychotropic Medication Consents: Two residents were not fully informed, per consent, of the dosage and frequency of their psychotropic/antidepressant meds. One resident’s Mirtazapine consent lacked the dose and administration frequency, and another resident’s single consent for hydroxyzine, trazodone, lurasidone, and duloxetine also omitted dose/frequency details and did not identify antidepressant side effects.
Surveyors found that the facility failed to obtain proper consent and provide adequate notification to resident representatives for care and treatment involving two residents. One resident with schizoaffective disorder and documented inability to make medical decisions received antipsychotic and antianxiety medications based on consent recorded as obtained from the resident, even though the resident’s representative did not consent. Another resident with paranoid schizophrenia and co-guardians was sent to offsite medical and mental health appointments without the co-guardians being informed or present, and in one instance the resident attended alone. The staff member responsible for scheduling appointments described informal and undocumented methods of notifying the guardian, and could not provide evidence that the guardian had been properly informed.
Failure to obtain informed consent for psychotropic meds was identified for 3 residents. One resident with dementia and depression had active orders for fluoxetine and bupropion with no consent on file, another resident with dementia and depression had orders for Ativan and sertraline with no consent on file, and a third resident with dementia, MDD, agitation, and restlessness had orders for hydroxyzine and escitalopram. The DON stated informed consent/risk-benefit review was only completed for antipsychotics, and the SSC could not provide documentation of collaboration for the resident on psychotropic meds.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.