A resident with diabetes, dementia, and CHF was started on Diazepam for anxiety, but the clinical record lacked evidence that the resident and/or representative were informed in advance of the medication’s risks, benefits, and alternative treatments. The DON confirmed the missing documentation, and the facility policy required RN-obtained consent and notification of the resident’s representative regarding desired effects and potential side effects.
The facility failed to inform a resident and/or the resident representative in advance of the risks, benefits, and alternative treatments before starting Zoloft, a psychotropic medication. The resident had diagnoses including depression and mood disorder, and the record lacked evidence of the required advance notification. The DON confirmed the missing documentation.
Failure to obtain informed consent for psychotropic medications was identified for three residents. One resident with dementia, anxiety, psychosis, CHF, and depression had an order for quetiapine without an informed consent form in the record, while two other residents had orders for paroxetine, divalproex, and lorazepam with no documented informed consent. The NHA and DON confirmed the missing consents during interview.
Failure to Obtain Signed Medication Consent: A resident with anxiety, depression, and ALS was ordered Duloxetine for major depressive disorder and Lorazepam for anxiety, but the record lacked a signed consent form showing the resident or responsible party was informed in advance of the proposed meds, including the risks and benefits. An ADON later produced a consent form, but it was unsigned by the resident or responsible party.
Failure to notify a resident’s representative of a medication change: A resident with Alzheimer’s Disease and hypertensive heart disease had a GDR of Memantine (Namenda) recommended by pharmacy and approved by the provider. An LPN documented that the medication was no longer effective in end-stage dementia and that orders were received to titrate the resident off, but the record did not show that the responsible party was informed, and the LPN could not recall whether notification occurred.
A resident with diabetes, CKD, and anxiety had escalating behaviors, including aggression, refusal of meds, throwing items, and spitting on staff. The family requested a UA to rule out a UTI, but the record did not show the test was completed or that the resident’s representative was informed why it was not done before the resident was sent to the ER and later returned with a UTI diagnosis and an order for Cefuroxime.
Failure to obtain informed consent for psychotropic medication changes. Two residents with dementia and other psychiatric diagnoses received increases in psychotropic meds, including an antidepressant, an anxiolytic, and an antipsychotic, but the clinical record had no documented evidence that the resident representative was informed in advance of the risks and benefits or treatment alternatives before the dose changes.
A resident with anxiety disorder and unspecified dementia was observed wearing an ankle monitoring device ordered to prevent elopement. The clinical record contained no documentation that the resident's family or representative was notified of the wander guard use, and the DON confirmed the unit manager did not call the family to inform them of the device.
A resident with dementia, anxiety, and depression was restarted on risperidone for agitation/verbal aggression after a failed GDR, but the record did not show that the resident representative was informed in advance of the medication’s risks, benefits, and treatment alternatives. The DON confirmed there was no documented informed consent before the antipsychotic was initiated, and that families had previously been notified of order changes without discussion of risks, benefits, or alternative interventions.
Failure to obtain informed consent for psychotropic meds: A resident with metabolic encephalopathy, dementia, and anxiety received lorazepam PRN and sertraline without documentation that the resident or responsible party was informed in advance about the benefits and potential side effects or that consent was obtained. The DON confirmed the resident and responsible party were not educated on the risks and benefits before the meds were given.
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