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.
Incomplete informed consent for psychotropic medications: Two residents received quetiapine and sertraline, but the consent forms were missing required details such as side effects, dates, signatures, and approval/denial documentation. Staff interviews confirmed the consents were not in the chart when reviewed, and the DON stated informed consent should include the medication, dose, reason, benefits, side effects, and date.
Failure to obtain and document informed consent for psychotropic medications was identified for two residents. One resident with severely impaired cognition, schizophrenia, and a feeding tube received Haloperidol via G-tube multiple times without a signed consent or documentation that risks, benefits, and alternatives were discussed with the resident representative. Another resident with moderate cognitive impairment received Seroquel nightly without evidence of advance education or consent, and the DON stated consents were not completed because the meds had been started in the hospital.
A resident with dementia and depression, who was cognitively intact and receiving citalopram for major depressive disorder, did not have a documented informed consent for psychotropic medication use. Staff interviews and policy review confirmed that the required process of providing information on risks, benefits, and alternatives, and obtaining a signed consent, was not completed.
Two residents with severe cognitive impairment and complex medical histories were administered psychotropic medications without documented informed consent or explanation of risks and benefits. Family members and staff confirmed that required consent forms were missing from the medical records, and the facility's policy did not address the informed consent process for these medications.
A resident with multiple sclerosis and persistent pain was prescribed and administered oxycodone without being provided education or informed consent regarding the risks and benefits of opioid use. Staff and leadership confirmed that the required education was not completed, despite facility policy mandating such education for high-risk medications.
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