Analyzing the Specific Deficiency


What actions should a facility take given a deficient practice statement that says the following?


Based on interviews and record reviews, 2 of 4 sample individuals were started on psychoactive medication regimens for inappropriate behaviors before written informed consent was obtained.


W263 was cited.


Six of 6 individuals at this facility are on psychoactive medication regimens and could be affected and have the potential to receive medications without consent.


The facility's PoC should address the following questions:

  • Are any other consents lacking?
  • How will the facility ensure that any lacking informed consents will be obtained for individuals on psychotropic medication regimens?
  • What process led to individuals receiving psychotropic medication without written consent and how will it be corrected?


Informed consent is required for all individuals taking psychotropic medication. The facility would need to document when the individuals' consents were obtained.


Note: This is not a comprehensive list of all the possible items the facility would need to address.



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