Failure to obtain psychotropic medication consent before initiation or continuation of ordered meds affected three residents. One resident with anxiety and depression received buspirone and escitalopram, another resident with anxiety/depression received mirtazapine, and a third resident with major depression received sertraline; in each case, the MAR showed the meds were given as ordered, but the record lacked documentation that the resident or representative was informed in advance of the risks and benefits. The DON, Psychiatric NP, Medical Director, and Administrator stated consent was required for psychotropic meds, including when residents were admitted on them or when doses were increased.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility administered psychotropic medications to multiple residents, including antidepressants, antianxiety medications, and trazodone, without documented advance consent or evidence that the resident or RP was informed of the risks and benefits before the medications were started. Records showed missing consent forms for several ordered medications, and residents who were able to respond stated they had not been educated or asked to sign consent before receiving the drugs.
Failure to obtain informed consent for psychotropic medications: A resident with mood and anxiety disorders had psychotropic dose changes that were not properly reflected on the consent form, another resident with dementia received alprazolam and quetiapine before the RP was educated or consent was obtained, and a third resident receiving multiple psychotropics had no consent form in the chart. Staff and the DON acknowledged that consents were not consistently completed and that education about medication risks, benefits, and alternate treatments was not always provided before administration.
Failure to obtain informed consent for psychotropic medications was identified for two residents. One resident with anxiety and severe cognitive impairment was started on Buspirone without documentation that the RP was informed in advance of the risks and benefits, and the RP later said he was only contacted after the medication had already been started. Another resident with depression and anxiety had orders for Duloxetine and Buspirone, but there was no consent form showing the resident had been informed of the risks and benefits; the resident did not recall any consent discussion, and the DON said the consents had been missed.
Failure to Obtain Psychotropic Medication Consent: The facility administered psychotropic medications to several residents, including antidepressants, an antipsychotic, and an antianxiety medication, without documented proof that the residents or their representatives were informed in advance of the risks and benefits or signed consent forms. Interviews with residents, the DON, Unit Manager, Psychiatric NP, Medical Director, and Consulting Pharmacist confirmed that consent was required when psychotropic medications were started or increased, but the records for the affected residents did not show that this occurred.
Failure to Obtain Consent for Psychotropic Medications: The facility administered psychotropic meds to multiple residents, including antipsychotics, antidepressants, and antianxiety agents, without documented consent or evidence that the resident or representative was informed in advance of the risks and benefits. Records showed orders for medications such as quetiapine, Seroquel, duloxetine, sertraline, mirtazapine, trazodone, diazepam, fluoxetine, buspirone, escitalopram, and Risperdal Consta, while interviews confirmed that consent was sometimes not obtained before administration.
Failure to obtain medication-specific informed consent for psychotropic drugs: The facility administered antipsychotic medications to four residents with diagnoses including dementia, Parkinson’s disease, and psychotic disorders, but the EMR lacked documentation that the residents or their RRs/Guardian were informed in advance of the risks, benefits, and treatment alternatives. The only consents in the records were general psychotropic medication forms signed on admission, and interviews showed the DON, Administrator, Medical Director, and Psychiatric NP had differing understandings of who was responsible for obtaining informed consent.
Failure to obtain informed consent for psychotropic medications: Two residents with dementia, anxiety, and depression received antianxiety, antidepressant, and antipsychotic medications without documentation that they or their Responsible Parties were informed in advance of the risks and benefits or consented to treatment. The MARs showed the medications were administered as ordered, while interviews with the DON, Social Services, Psychiatric NP, and Administrator confirmed the facility was not obtaining or auditing informed consents for psychotropic medications.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
The facility failed to obtain and document informed consent, including discussion of risks and benefits, before initiating or increasing psychotropic medications for three residents receiving antianxiety and antidepressant drugs. Cognitively intact residents reported that no provider or staff discussed side effects or risks and benefits when their alprazolam, sertraline, Xanax, or Zoloft were started or increased, and a responsible party for a severely cognitively impaired resident did not recall any discussion when buspirone was initiated. Records lacked documentation of informed consent, while interviews with the NP, Medical Director, Rounding Nurse, DON, Informatics Nurse, and Consulting Pharmacist revealed that nursing staff were expected to handle psychotropic consents, but consents were only being obtained for new antipsychotic orders and not for residents admitted on psychotropics or for antidepressant and antianxiety medications, despite policy defining these as psychotropics.
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