HospitalInspections.org

Based on review of medical records interview, and review of facility policy, the facility failed to protect the patient's right to make informed decisions about their care, as psychoactive medications were given to patients (#s 1 and 2) without first obtaining the appropriate informed consents. This failure placed 2 of 10 patients (#s 1 and 2 ) reviewed for infomed consent at risk for not being involved in care planning and treatment decisions, and not being able to request or refuse treatment.

Findings were:

Review of medical record for patient #1 reflected admission to the facility on 12/27/23 and discharge on 12/30/23.

Review of an electronic medication administration record (eMAR) revealed that patient #1 was administered:
- Olanzapine (a medication that can treat mental disorders) on 12/28/23 at 8:50 PM, and
- Sertraline (a medication that can treat depression and anxiety) on 12/29/23 at 9:30 AM.

No consent was found in patient #1's medical record for Olanzapine or Sertraline.

Interview on 2/14/23 at 10:15 AM with Staff #1, Chief Nursing Officer, confirmed consents for Olanzapine and Sertraline were not found.

Review of a census report for 2/14/204 documented patient #2 was admitted to the facility on 2/1/24.

Review of an EMR revealed that patient #2 was first administered Donepezil (a medication that can treat Alzheimer's disease) on 2/1/23 at 9:00 PM.

An "Informed Consent for Psychotropic Medications" form for Donezepil documented patient #2 signed the consent on 2/2/23.

Interview on 2/14/23 at 10:15 AM with staff #1, confirmed patient #2 received a dose of Donezepil on 2/1/24, before patient signature was obtained.

Review of the facility policy, "Consent to Psychotropic Medication" last review date 6/28/22, documented in part: " ... Procedure ... Prior to the administration of the medication, the Consent to Receive Psychopharmacological Medications Form must be signed by the patient. No nurse may administer the prescribed medication(s) until this form is completed ..."