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.
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.
A resident with multiple chronic conditions, including dementia and schizoaffective disorder, experienced a change in condition with shortness of breath and was moved overnight to a secured unit for closer monitoring. Record review showed no consent form for this placement, despite facility policy requiring consent for admission to the secured/locked area. In interviews, an LVN confirmed that consent is required for secured unit placement, and the DON acknowledged that no consent was obtained for this resident and that this was against the resident’s rights.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke received quetiapine, including a dosage increase, without required written consent. Physician orders and the MAR showed the antipsychotic was initiated and then increased, but the EMR lacked HHSC Form 3713 and any signed consent from the resident or representative. A facility consent form for Seroquel had no signature, and a prior ADON documented only a verbal consent without evidence that side effects were explained or understood. In interviews, an LVN and the CCN confirmed that facility policy and state guidance require signed written consent, not verbal consent, before administering antipsychotic medications, and acknowledged that no valid consent or updated consent for the dosage change was on file.
A resident with a history of stroke-related hemiplegia, T2DM, and lack of coordination, and documented as moderately cognitively impaired, was started on Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before the resident’s legal representative signed the psychoactive medication informed consent form, and when the form was later signed, the section indicating whether consent was granted was not completed. During interview, the DON confirmed that the consent for Trazodone was not properly completed prior to administration, despite facility policy requiring review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
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