Failure to document informed consent for psychotropic meds: A resident with schizoaffective disorder, bipolar disorder, anxiety, and insomnia was ordered clonazepam, divalproex ER, olanzapine, and trazodone, but the consent form only listed clonazepam and trazodone. The CM acknowledged omitting Depakote ER and olanzapine and missing the antipsychotic box, and the DON stated the form lacked documentation that the resident received those meds.
A resident with dementia and depression, who was cognitively intact and receiving citalopram for major depressive disorder, did not have a documented informed consent for psychotropic medication use. Staff interviews and policy review confirmed that the required process of providing information on risks, benefits, and alternatives, and obtaining a signed consent, was not completed.
Two residents with severe cognitive impairment and complex medical histories were administered psychotropic medications without documented informed consent or explanation of risks and benefits. Family members and staff confirmed that required consent forms were missing from the medical records, and the facility's policy did not address the informed consent process for these medications.
A resident with multiple sclerosis and persistent pain was prescribed and administered oxycodone without being provided education or informed consent regarding the risks and benefits of opioid use. Staff and leadership confirmed that the required education was not completed, despite facility policy mandating such education for high-risk medications.
The facility did not obtain or document informed consent, including discussion of risks and benefits, before administering psychotropic medications to four residents with varying cognitive and medical conditions. Medical records lacked signed consent forms and evidence of education or notification to residents or their representatives. Nursing staff interviews revealed uncertainty about who was responsible for obtaining consent, and no policy on residents' rights regarding medications was provided.
The facility did not obtain or document informed consent, including discussion of risks and benefits, before administering psychotropic medications to several residents with cognitive and psychiatric conditions. Medical records lacked evidence of completed consent forms or documentation that residents or their representatives were informed, despite facility policy and staff expectations requiring this process.
A resident with impaired cognition and multiple diagnoses was administered psychotropic medications, including lorazepam and risperidone, without documented informed consent from the responsible party. Despite facility policy requiring consent and education on medication use and changes, the necessary documentation was not found in the medical record, as confirmed by the DON.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed Lexapro, a psychotropic medication, without documented informed consent from the resident or their representative. Staff interviews and facility policy confirmed that informed consent should have been obtained and documented prior to starting the medication, but no such documentation was found in the resident's record.
A facility failed to notify a resident's representative about the discontinuation of a PRN Lasix prescription for CHF-related edema. Despite the resident's significant medical conditions, including dementia and CHF, the family was not informed of the medication change, which was confirmed by the DON. This oversight violated the facility's policy on promptly notifying changes in medical care.
A resident with a primary language of Somali and cognitive impairments was not provided with adequate interpretive services, leading to a lack of understanding about his health status and treatment plan. Despite documented needs for an interpreter, the facility relied on inconsistent methods for communication, resulting in the resident's frustration and refusal of care.
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