Missing Informed Consent for Psychotropic Medications: Five residents received psychotropic meds, including antidepressants and antianxiety agents, without signed consent forms in the chart. The residents included individuals with intact cognition as well as residents with dementia or severe cognitive impairment. The DON stated the consents had not been signed, and the ADM said she was unaware the forms were missing until the day of the interview. The facility’s psychotropic medication policy did not address medication consents, and no informed consent policy was provided.
A resident with moderate dementia and severe cognitive impairment was started on Zyprexa after a MH NP changed her medication regimen, and physician orders documented its use for depression and later unspecified psychosis. Progress notes showed that the responsible party (RP) was informed of psychiatric recommendations and was later contacted multiple times regarding a pending consent form, and also requested discontinuation of Zyprexa while the consent remained unsigned. Despite this, the MAR showed that Zyprexa was administered on two occasions before any written consent was obtained, contrary to staff statements and facility policy requiring a signed antipsychotic consent from the resident or RP and the prescriber, and prior disclosure of risks, benefits, and alternatives.
Surveyors identified that the facility did not obtain required signed consents or adequately ensure resident/responsible party participation for psychotropic medications for two residents with severe cognitive deficits and multiple psychiatric diagnoses. One resident received Ativan, Oxcarbazepine, and Nuplazid for agitation and psychosis without signed consents for two antipsychotics, despite being care planned for psychotropic use and having severe cognitive impairment. Another resident with dementia, depression, anxiety, and behaviors was observed drowsy and slurring speech while on scheduled and PRN Ativan, and the responsible party reported the drug calmed behavior but caused drowsiness; however, no signed consent for the antipsychotic medication was found. The DON stated that EHR-generated consents were sufficient and that signed consents were not needed for Ativan used for anxiety, even though the facility’s psychotropic policy and the EHR consent form instructions required a printed, resident/RP-signed consent for each psychoactive medication.
A resident with intact cognition received Olanzapine for major depressive disorder with psychotic symptoms, but the medication consent form in the chart was not signed by the resident or RP. The care plan addressed psychotropic medication education, the MAR showed daily administration, and staff interviews confirmed the facility expected signed consent to be in place before starting psychotropic meds.
Missing Psychotropic Medication Consents: The facility administered psychotropic meds to several residents without the required documented consents in place. A cognitively intact resident received Divalproex without a medication-specific consent in the EMR, a moderately impaired resident received Sertraline before the consent was properly available in the chart, and two other residents had psychotropic orders without the required Form 3713 documentation for antipsychotic/neuroleptic use. Staff interviews confirmed the consent gaps and that the required forms were not consistently present in the record.
Failure to obtain informed consent for an antipsychotic medication before administration. A resident with major depressive disorder and hallucinations, who had intact cognition and a BIMS of 15, was ordered Olanzapine 5 mg BID for hallucinations and received it daily without a signed consent in the EMR at the time of review. A later-scanned consent form was dated after the medication had already been given, and the ED, DON, and Administrator stated consents were expected before administration.
A deaf and mute resident with traumatic brain injury, schizoaffective disorder, and paraplegia was not provided effective communication to understand and participate in care and treatment. Although orders and the care plan called for sign language, interpreter services, and use of a communication device, staff largely relied on hand gestures and head nods, and key staff were unaware of or did not implement video relay services. The resident had limited reading and writing skills and could not lip read, contrary to assumptions by leadership. Staff identified as interpreters had only basic ASL skills and no formal training or certification, and there were no clear Kardex or care plan instructions for consistent use of qualified ASL or VRS services, resulting in ineffective communication about the resident’s health status and treatments.
A resident with advanced dementia and multiple comorbidities had a longstanding insulin regimen for type 2 DM discontinued and replaced with Metformin by an NP without prior notification to or consent from the resident’s family. Facility records showed the sequence of orders changing from Lantus to varying doses of Metformin and later back to insulin, with MARs indicating medications were given as ordered. The family later reported the resident developed symptoms they associated with Metformin and stated they would not have agreed to the change if informed. In interviews, the NP admitted she did not consult the family before changing the treatment, acknowledged this was a mistake, and recognized the resident’s and family’s right to be informed of treatment changes, risks, benefits, and alternatives. The MD and DON confirmed that the NP failed to communicate the medication change to the family, and staff described that residents have the right to know about medication changes and to accept or refuse treatment, demonstrating a failure to follow the facility’s resident rights policy.
A cognitively intact male resident with bipolar disorder was prescribed medroxyprogesterone acetate (Provera) 5 mg daily by an NP for sexual behaviors, despite no sexual behaviors being addressed in his care plan. The MAR showed he received two doses, and a nursing note documented he was started on Provera and paroxetine with general medication education, but there was no signed consent for Provera on file. The resident later reported he learned from an outside case manager that he had been prescribed a hormone without his knowledge, stated he had not signed consent and did not want medication for his sex drive, and interviews confirmed the psych physician had not ordered Provera and that the facility had no written consent policy available. The DON and ADON acknowledged responsibility for obtaining consents lay with the prescriber or the nurse taking the order, yet no consent form for Provera could be produced.
The facility failed to ensure two residents were fully informed and able to communicate their health status, care, and treatments in languages they could understand. A Spanish-speaking resident said she could not effectively tell staff about complaints, medications, meals, or other needs, and staff were observed providing care while speaking only English and using gestures. A Vietnamese-speaking resident with dementia and other diagnoses was not identified in the care plan as speaking Vietnamese, relied on family or a translation line to express needs, and staff initially missed her report of a sore throat and pain because communication was handled in English or through informal methods.
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