Failure to obtain informed consent for psychotropic medications. The DON confirmed that the facility did not educate or obtain consent before giving psychotropic meds to multiple residents. One resident had antidepressants ordered without any consent in the record, another had a psychotropic consent form that did not list the meds, risks, benefits, or non-pharmacological alternatives, and a cognitively intact resident receiving Rexulti had an incomplete consent form with no signatures or dates.
Failure to document informed consent for psychotropic medications for two residents. One resident with dementia, agitation, anxiety, and depression received Risperidone and Escitalopram without consent documentation, and the DON confirmed no consent was on file. Another resident had orders for Pregabalin, Hydroxyzine, Donepezil, and Fluoxetine, but the record contained no informed consent for psychotropic meds, and the Regional Corporate Nurse confirmed the lack of documentation.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives: Surveyors found that the DON confirmed residents receiving psychotropic meds were not given signed forms or advance discussion of risks, benefits, and alternatives before administration. Records for several residents with diagnoses such as dementia, depression, schizoaffective disorder, bipolar disorder, Alzheimer’s disease, and Down syndrome showed orders for antipsychotics and antidepressants, but no evidence that the resident and/or representative was informed in advance of care.
A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had orders for clonazepam PRN and lamotrigine at HS, but the EMR contained no evidence of informed consent or documentation that benefits and side effects were explained for either psychotropic medication. The ADON confirmed the missing consent in the resident's record.
Surveyors found that the facility did not ensure residents and their POAs were informed of the risks, benefits, side effects, and alternative/non-pharmacological options before initiating or continuing antipsychotic and other psychotropic medications, and did not notify a POA of new skin conditions. Several residents with diagnoses including delusional disorder, anxiety, bipolar disorder, dementia, and major depressive disorder were receiving medications such as Risperidone, Depakote, Risperdal, Xanax, Mirtazapine, Olanzapine, and a compounded topical Ativan/Benadryl/Haldol preparation. Facility policy required education on psychotropic drug use, but medical records and care plan notes lacked specific documentation of risk/benefit and alternative treatment education, and the DON acknowledged that POAs were not informed prior to prescriptions being written and dispensed. In addition, one resident developed multiple new foot and heel wounds, yet the POA reported being unaware of any skin issues, and an LPN confirmed there was no communication to the POA about these wounds or related interventions.
The facility did not provide or document risk versus benefit information for psychotropic medications to two residents and their representatives. Despite multiple medication changes and the use of high-risk drugs, there was no evidence that risks, benefits, options, or alternatives were discussed or acknowledged. Staff confirmed that the facility did not have a process for reviewing or documenting this information.
A resident receiving multiple psychotropic medications for anxiety and depression did not have documented education or informed consent for their use, despite facility policy requiring this prior to medication initiation or increase. The DON confirmed the absence of a psychotropic consent form in the resident's record.
Two residents receiving antipsychotic medications, including one with severe cognitive impairment and another with multiple psychiatric diagnoses, were not provided or documented with education regarding the risks, benefits, or alternative treatments for these medications. Facility staff confirmed the absence of such documentation, resulting in a deficiency related to informed consent for antipsychotic use.
Three residents, including individuals with schizophrenia, dementia, and other serious conditions, were administered psychotropic medications without documented informed consent. Facility records lacked evidence that residents or their representatives were informed of the benefits, risks, and alternatives to these medications, and staff confirmed that required consent documentation was missing or incomplete.
A facility failed to inform a resident about changes to their Metformin medication, leading to the resident refusing the medication due to lack of notification. The resident, who was cognitively intact, had a care plan goal to direct their care but lacked interventions for this goal. Additionally, another resident with dementia had not been re-evaluated for eye care needs since admission, despite declining an eye exam initially. The facility did not document any follow-up on the resident's vision care needs.
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