Failure to inform residents of risks and benefits before psychotropic medications were started. The facility had no documentation of consent or education for multiple residents receiving antipsychotics, antidepressants, antiseizure medications used as mood stabilizers, and antianxiety medications. Residents had diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, dementia, depression, anxiety, PTSD, and other behavioral or neurologic conditions. One resident said he/she did not recall staff explaining the risks and benefits, and an LPN and the DON said they expected residents and/or representatives to be informed.
Failure to Obtain Written Consent for Psychotropic Medications: The facility did not document written consent before starting psychotropic meds for four residents. Records showed no informed consent for antipsychotic, antidepressant, or anticonvulsant use for residents with diagnoses including dementia, stroke, depression, psychotic disorder, and impaired cognition. The DON and Administrator acknowledged that written consents should have been in the medical record.
Failure to obtain written consent before starting psychotropic medications for three residents. One resident had intact cognition and was receiving diazepam and quetiapine, while two others had impaired cognition and were receiving antianxiety, antipsychotic, and antidepressant medications. Records showed no signed consents before or after the meds were started, and interviews confirmed the DPOA had not been asked to sign paperwork and staff were unsure who was responsible for obtaining psychotropic consent.
A resident who was cognitively intact and recently admitted after pacemaker placement was not fully informed before a CNA, who was not regularly assigned to them, applied barrier cream to their perineal area. The resident experienced discomfort and distress, reporting that they had not previously received this care and were not told why it was being done. Staff interviews confirmed that residents are expected to be informed of all care, and that this protocol was not followed in this case.
A contracted PTA did not adequately explain therapy procedures or obtain informed consent before providing treatments to several residents, resulting in confusion and discomfort. Multiple residents with various medical conditions reported that the PTA initiated physical contact, including touching near the chest and abdomen, without prior explanation, causing them to feel uneasy or distressed. Interviews confirmed that proper communication protocols were not followed, leading to a deficiency in upholding residents' rights.
A resident with moderate cognitive impairment and lung cancer underwent lung surgery without the facility notifying the legal guardian (Public Administrator) in advance, as required by policy. Documentation and staff interviews confirmed that the PA was not informed prior to the procedure, and the lack of communication was attributed to administrative changes and missing documentation. The PA only learned of the surgery after the resident called following the procedure.
The facility failed to inform a resident and/or their representative of the risks and benefits of a physician-ordered antipsychotic medication. The resident, who had moderate cognitive impairment, was not aware of the purpose of the medication, and no consent was documented. The Unit Manager confirmed the lack of consent, and the facility did not provide a relevant policy.
The facility failed to inform a resident and/or their representative about the risks and benefits of prescribed psychotropic medications. The resident, who was cognitively intact, was not informed about the medications Seroquel and Rexulti, and the documentation in the Progress Notes was incomplete. Interviews with staff confirmed that the process for informing residents was not properly followed.
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