A resident with schizophrenia, HTN, and MDD with psychotic features, and documented severe cognitive impairment requiring substantial/maximal assistance with ADLs, was receiving Quetiapine (Seroquel) 100 mg PO daily without documented informed consent. The ADON reported that antipsychotic consents are required on admission and with new orders and must include the medication name, dose, route, and frequency, but confirmed there was no consent on file for this antipsychotic. Facility policy on informed consent for psychotropic drugs required disclosure of reasons for use, benefits, risks (including black box warnings), and alternatives to the resident or RP, yet this process was not completed for the resident’s Seroquel order.
A resident with dementia, diabetes, and HTN had bilateral upper and lower half side rails up and locked in bed, but staff could only locate informed consent for the upper side rails. RN, ADON, and DON all confirmed that no signed consent could be found for the lower side rails, despite the facility policy requiring informed consent from the resident or POA before using side rails.
Failure to Obtain Valid Informed Consent for Psychotropic Medication: A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder was documented in the H&P as lacking capacity to understand and make decisions, yet the consent for Zyprexa was obtained from the resident rather than a responsible party. RN and DON interviews confirmed the resident could not consent to the psychotropic medication, while the MAR showed Zyprexa was administered after the improper consent was documented.
A resident with severe cognitive impairment and no decision-making capacity was prescribed multiple psychotropic medications, including Depakote, mirtazapine, Seroquel, and PRN olanzapine. The informed consent forms signed by the resident’s responsible party were incomplete or inaccurate, with missing drug categories and durations, incorrect documentation of off-label use, and side effects listed under the wrong drug classification. Facility leadership and clinical staff acknowledged that these forms should have been fully and accurately completed so the responsible party could understand the risks, benefits, and purposes of the medications before consenting.
A resident with dementia and an anxiety disorder received PRN lorazepam for agitation without documented informed consent. The MAR showed five doses were given, and the DON and ADON verified the record lacked consent; the ADON stated the nurse who received the order did not obtain it and thought hospice would.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
An LPN gave medication cups to four residents without explaining what medications were being administered, and each resident swallowed the pills. The residents had diagnoses including DM, COPD, schizophrenia, bipolar disorder, anxiety, dementia, and HTN, and records showed varying capacity to understand and make decisions. During interview, the LPN stated residents should be told what medication they are receiving if they ask, and that they need to know in case they want to refuse.
The facility failed to ensure informed consent was properly completed for psychotropic medications for two residents. One resident with moderate cognitive impairment had a single consent form covering aripiprazole, clonazepam, and lorazepam, with aripiprazole misclassified as an antidepressant and no separate consent or nonpharmacological interventions for each medication. Another resident with severe cognitive impairment had consent forms for mirtazapine and olanzapine that were not signed by the physician and also lacked separate consent and intervention documentation for each drug.
Failure to Inform Residents of Medications Before Administration: An LVN administered multiple medications to one resident with anxiety disorder and another resident with epilepsy, HTN, and delusional disorder without first telling them the medication names or indications. The residents were not given the opportunity to consent or refuse, and one resident stated she was uninformed of each medication. The DON stated LVNs are expected to review and name each medication before administration, and the facility’s Resident Rights policy required residents to be informed of and participate in their care and treatment.
A resident with schizophrenia, major depressive disorder, and severe cognitive impairment received multiple psychotropic medications, including an antidepressant, mood stabilizer, anticonvulsant used as a mood stabilizer, and antipsychotics, before the prescribing practitioner’s consent process was confirmed with the resident’s conservator. The MAR and provider notes showed the medications were administered without documented informed consent, and staff interviews confirmed that consent was required before administration.
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