Failure to obtain consent and provide psychotropic medication education: A resident with late onset Alzheimer’s Disease was started on multiple psychotropic meds, including an antidepressant, antipsychotic, antianxiety med, and another antidepressant, but the EHR did not show consent before initial administration. There were also no progress notes or assessments documenting education on side effects, risks vs benefits, or offering alternative treatments before the meds were given, despite facility policy requiring informed consent and discussion of nonpharmacological approaches and medication alternatives.
Failure to Document Consent and Education for Psychotropic Medications: The facility did not document consent, resident education, or discussion of alternative treatments before giving psychotropic medications to four residents with diagnoses including dementia, anxiety, depression, PTSD, insomnia, and bipolar disorder. Records showed orders for antidepressants, antianxiety medications, antipsychotics, and hypnotic agents, but no progress notes or assessments reflected education on risks and benefits or that alternatives were offered, and the facility had no policy for psychotropic medication use.
The facility did not obtain or document informed consent for antipsychotic medications for two residents with impaired cognition. Although staff reportedly discussed the medications with family members, there was no documentation of completed consent forms outlining the risks and benefits prior to starting the medications, as required by facility policy.
A resident with moderate cognitive impairment and diagnoses of dementia and depression was administered risperidone, an antipsychotic medication, without documented informed consent from the responsible party. Staff interviews and record reviews confirmed that the required consent process was not followed, and the care plan did not reflect the use of the medication, contrary to facility policy.
The facility did not provide or document advance information to residents or their representatives regarding the risks and benefits of prescribed psychotropic medications. Multiple residents with conditions such as dementia, anxiety, depression, and other chronic illnesses received medications like antidepressants and antipsychotics without documented informed consent, as confirmed by staff interviews and record reviews.
A resident with moderate cognitive impairment and intellectual disability, who was frequently disoriented and unable to make complex decisions, did not have a designated representative for medical or financial decisions. Staff and administration confirmed that no attempts were made to identify or assign a POA, conservator, or guardian, despite facility policy and care plan directives requiring such action.
A resident with severe cognitive impairment and multiple psychiatric diagnoses underwent changes in psychotropic medications without documented education or informed consent from the resident or their representative. The facility's records showed only an attempted phone notification to the family, with no follow-up or signed consent form, and the facility's policy did not address informed consent requirements for such medication changes.
Two residents with severe cognitive impairment experienced changes to high-risk medications without documentation that their representatives were notified or consented, despite facility policy requiring such communication. Staff interviews confirmed the expectation for notification, but clinical records lacked evidence that representatives were informed about the medication changes.
A resident with intact cognition and multiple diagnoses fell and sustained a head injury, but the family was not notified as required by the facility's policy. The LPN informed the PCP but failed to contact the family, believing the injury was minor. The DON acknowledged this failure, which was against the policy mandating family notification after incidents.
A resident with no cognitive impairment was excluded from decision-making regarding their dietary needs, despite expressing dissatisfaction with a ground meat diet and requesting a reevaluation. The facility relied on a Durable Power of Healthcare document to direct decisions to the family, assuming the resident was unable to make decisions, which was not the case. Delays in a speech evaluation were due to insurance and co-pay issues.
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