09/10/2026

You Asked... We Answered

You Asked: What are the requirements for obtaining and documenting a resident’s consent before initiating or increasing a medication? 

We Answered: In accordance with the requirements at §483.10(c), residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a medication. To demonstrate compliance, the resident’s medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident’s consent to medication, but other types of documentation are also acceptable. If a medication has been initiated or increased, and there is no documentation demonstrating compliance with the resident’s right to be informed and participate in their treatment, noncompliance with §483.10(c) exists and F552 must be cited.