The facility failed to document and offer nonpharmacological treatment options when obtaining consent for psychotropic medications for several residents. A resident with PTSD, anxiety, and depression; a resident with severe cognitive impairment and dementia; and two residents with dementia-related behaviors received antipsychotic, antianxiety, and/or antidepressant medications, and consent forms were completed, but the records did not show that alternate treatment interventions were presented. The DON confirmed the facility had no evidence that these options were provided with the psychotropic medication consents.
Failure to obtain informed consent before starting psychotropic medications. Multiple residents with diagnoses including dementia, depression, anxiety, and agitation were started on psychotropic medications such as antipsychotics, antidepressants, and benzodiazepines without documented advance consent from the resident or representative. In several cases, later consent forms were present, but the DON confirmed consent had not been completed before the medications were initiated, and one resident stated the signature on the form was not theirs.
Incomplete informed consent for psychotropic medications: The facility failed to document comprehensive consent before giving psychotropic meds to multiple residents. Consent forms for antipsychotic, antidepressant, and antianxiety meds did not include dose or frequency, symptoms being treated, adverse effects, nonpharmacological interventions, or treatment alternatives. The DON, MDS Coordinator, and RN confirmed the missing information for residents with dementia, depression, anxiety, and behavioral symptoms.
Incomplete informed consent for psychotropic medications: The facility failed to ensure a resident or representative was fully informed before psychotropic meds were started or increased. Records for multiple residents showed consent forms that omitted dose, frequency, symptoms being treated, potential adverse effects, and alternative or non-pharmacological options for meds such as Alprazolam, Zoloft, Trazodone, Seroquel, Ativan, Cymbalta, Rexulti, Wellbutrin, Paroxetine, Lorazepam, Quetiapine, and Sertraline. The DON confirmed several consents were incomplete or missing.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility administered psychotropic medications to multiple residents, including antidepressants and antipsychotics, without documented informed consent from the resident or representative. Records for residents with depression, dementia with agitation, and schizophrenia showed orders for medications such as mirtazapine, Paxil, Seroquel, duloxetine, risperidone, and Lexapro, but no evidence of advance discussion of risks, benefits, or alternative treatment options.
Incomplete psychotropic medication consents were found for two residents, with forms missing diagnosis selections, side effect information, and consent acknowledgements for meds such as alprazolam, divalproex, paroxetine, quetiapine, and mirtazapine. For another resident with depression and dementia, the record showed an order for Abilify but no evidence of a psychotropic consent signed by the resident or POA. The DON, Facility Administrator, nurse manager, and SDN confirmed the consent forms were incomplete or missing.
Failure to Obtain Psychotropic Medication Consent Before Initiation or Dose Increase: The DON confirmed that consent forms for psychotropic meds were missing from the records for three sampled residents, and the forms were not completed before the meds were started or increased. One resident was cognitively intact with depression and was receiving an antipsychotic and an antidepressant; another had severe cognitive impairment, dementia, agitation, and was receiving an antipsychotic and lorazepam; the third was cognitively intact with depression, PTSD, and was receiving an antidepressant and an antipsychotic. The facility later obtained telephone consent from POAs, but the required consent documentation was not in place before treatment began.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not ensure informed consent was obtained before starting psychotropic medications for two residents. One resident with major depressive disorder was started on Seroquel without documented consent, and another resident with major depressive disorder, PTSD, irritability, and anger was started on Risperdal and Olanzapine without documented consent. The DON stated consent should be completed on admission for residents on psychotropics and when new psychotropic meds are initiated.
Incomplete informed consent for psychotropic meds was found for multiple residents. Records showed residents with diagnoses such as dementia, schizophrenia, anxiety, depression, bipolar disorder, PTSD, and brain dysfunction were receiving antipsychotic, antidepressant, and antianxiety meds, but the consent forms did not identify the specific diagnoses or symptoms being treated and often lacked potential effects, adverse effects, and alternative treatment options. One resident’s consent was undated and did not match current doses, and another resident had no evidence that consent was obtained before psychotropic meds were given.
The facility failed to obtain consent before administering psychoactive meds to two residents. One resident received several doses of Mirtazapine before the POA was contacted about the consent form, and another resident received doses of an increased Abilify order before the consent was signed. The facility policy required signed consent before use and with dose changes, and the FA confirmed consent should have been obtained before administration.
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