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Based on interview and record review, the facility failed to obtain consent for psychotropic medication prior to administration for one (#2) of two patients reviewed for informed consent, out of a total sample of 11 patients, resulting in the inability of the patient to make an informed decision regarding care. Findings include:

On 04/02/15, at 1300 review of the clinical record for Patient #2 revealed that the patient was admitted into the facility on 03/20/2015 as an involuntary patient, but had a status change and became a voluntary patient on 03/23/15.

The medication consent forms were reviewed on 04/02/15 at 1215 which revealed that Patient #2 signed an informed consent for treatment for psychoactive medication for Zyprexa on 03/24/15 however, the consent for the patient to receive Ativan (antianxiety medication) was not signed by Patient #2.

Review of Physician orders and the Medication Administration Record (MAR) revealed that Patient #2 received Ativan multiple times during her stay in the facility. According to the MAR, Ativan 1 mg was administered IM (intramuscular) on 03/21, 03/22, 03/23, 03/24, 03/26 and 03/29/15.

On 4/2/15 at 1300 a review of the policy titled, "WRITTEN INFORMED CONSENT FOR PSYCHOTROPIC MEDICATIONS" Dated 12/05 revealed, "...the hospital supports the practice of obtaining written informed consent for the administration of psychotropic medications..."

On 04/02/15 at 1500 the Director of Nurses confirmed that the consent should have been
signed prior to the medication administration.

Based on interview and record review the facility failed to ensure patient safety by ensuring that 1) medication for one (#1) of three patients reviewed for medications was put on hold as the physician recommended and 2) prn (as needed) narcotic medication orders for one (#8) of three patients reviewed had dosing limits resulting in the potential for adverse effects from a greater dose of medication than the patients required. Findings include:

Patient #1

On 04/01/2015 at 1430, a closed record review revealed that Patient #1 was admitted into the facility on 01/07/15 with hypothyroidism, schizoaffective disorder and a right middle toe infection among other diagnoses. Review of the progress noted dated 01/13/15 revealed that "...the patients TSH (thyroid stimulating hormone) level was 0.03 (normal range 0.27-4.20)...since the patient's TSH level 0.03, I discussed with the patient, she cannot have the levothyroxine at this moment. We will repeat the TSH level again..."

The lab reports dated 01/08/15 and 01/11/15 revealed that (#1's) TSH level was 0.03 and 0.04, respectfully.

The MAR (Medication administration record) revealed that patient #1 received Levothyroxine 150 mcg (micrograms) daily from 01/08/15 through her discharge date of 01/26/15.

There was no physicians order noted in the record indicating that the medication was supposed to be put on hold.

On 04/02/15 at 1145, an interview was conducted with Physician (G) who explained that she did intend for the medication to be put on hold because the TSH level was so low, however, the physician did not indicate why the physicians order was not written.


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Record Review:
On 4/2/15 at 1025 patient #8's clinical record was reviewed with staff B. A PRN (as needed) order for patient #8 dated 3/28/15 was reviewed. The order stated,"Ativan 1 mg. PO (by mouth) Q (every) 6 hours PRN, anxiety; Ativan 1 mg. IM (intramuscular injection) Q 6 hours PRN, anxiety; Haldol 5 mg. Q 6 hours PRN, agitation; Haldol 5 mg PO Q 6 hours PRN, agitation." The order did not state that these medications should be given either PO or IM, making it possible for the patient to receive 10 mg. of Haldol at one time for agitation, via both IM and PO routes, without physician notification. Six hours later, the patient could receive another 10 mg. of Haldol for agitation without physician notification.

Interview:
On 4/2/15 at 1025 Nurse B confirmed these findings during Record Review. Nurse B stated that the above medication order should have been written for PO or IM administration every 6 hours.