Failure to document informed consent for psychotropic meds: a resident with mildly impaired cognition, dementia, TBI, anxiety, and depression was receiving escitalopram and quetiapine, but the ADON could not find documentation that consent was obtained or that the risks, benefits, and alternative tx options were explained to the resident or resident representative. The facility policy required physician documentation of consent before starting a new psychotropic medication.
A cognitively intact resident with multiple diagnoses, including schizoaffective disorder and non-Alzheimer's dementia, had psychotropic medications ordered for depression and mood disorder, but the medical record lacked informed consent for mirtazapine. The DON stated psychotropic medication consents were obtained by the physician and should be in the chart, and confirmed the missing consent.
Failure to obtain consent for a psychotropic medication: A resident with severe cognitive impairment and diagnoses including dementia and insomnia was ordered trazodone for bedtime use, but the medical record lacked evidence that consent was obtained before the medication was used. RNs and the DON stated consent was expected for new psychotropic medications or when a resident was admitted on one, and the facility policy did not address consent for psychotropic use.
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, stroke, and non-Alzheimer's dementia was started on risperidone without documented informed consent from the resident or representative before administration. The EMR did not show consent prior to initiation, and the RN CM later obtained verbal consent from the family after the medication had already been started. The DON stated consent should have been obtained and signed before the psychotropic was given, consistent with the facility's psychotropic medication policy.
Failure to obtain informed consent for psychotropic medications. A resident with severe cognitive impairment and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and schizophrenia was prescribed Clozaril, Lexapro, lorazepam, and Olanzapine, but the record lacked evidence of consent with risk/benefit discussion for any of the medications. The DON stated the resident was not asked to sign because of cognitive concerns, despite the resident being their own decision maker and having windows of lucidity, and the decision was made without input from the resident or other IDT members.
Failure to document informed consent for psychotropic meds: A resident with schizoaffective disorder, bipolar disorder, anxiety, and insomnia was ordered clonazepam, divalproex ER, olanzapine, and trazodone, but the consent form only listed clonazepam and trazodone. The CM acknowledged omitting Depakote ER and olanzapine and missing the antipsychotic box, and the DON stated the form lacked documentation that the resident received those meds.
A resident with depression and insomnia was receiving duloxetine and trazodone, but the chart lacked documentation of informed consent, including discussion of risks, benefits, and alternatives. Staff interviews confirmed the LPN did not complete medication consents, the RN expected verbal consent to be documented in a note, and the DON stated the facility did not do written consents for psychotropic meds; the provider note also did not show that the required discussion occurred.
A resident with Alzheimer’s disease, anxiety, depression, psychotic disorder, and severely impaired cognitive decision-making skills was prescribed Seroquel for psychosis, but the medical record lacked evidence that informed consent for the current dose and frequency was obtained before administration. An LPN could not find documentation of consent and believed verbal consent may have been obtained, while the resident’s POA said he was not informed of the most recent antipsychotic medication updates. The unit RN stated floor nurses were responsible for contacting family, discussing risks and benefits, and obtaining consent, with the signed form uploaded to the chart.
Failure to document informed consent for psychotropic medications: A resident with intact cognition, complete paraplegia, and depression received PRN alprazolam, daily escitalopram, and later PRN clonazepam, but the record lacked evidence that consent was obtained or that the risks and expected benefits were discussed before the medications were started. The resident stated no one had explained the medications, and staff and the DON reported there was no process to document the details.
Failure to document informed consent for antipsychotic meds. A resident with moderately impaired cognition and delusions was receiving risperidone and Seroquel for psychosis/delirium, but the EMR had no signed consent for either medication. RN and DON stated psychotropic consents were to be obtained before starting or increasing meds, and the guardian said they were told about a new med for agitation but were not informed of the name, risks, or benefits and never signed a consent reviewing those details.
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