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Based on interview and record review the facility failed to obtain informed consent for the administration of psychotropic medications for 1 of 7 behavioral health patients (#1) out of a total sample of 7 resulting in the withholding of information required by the patient or patients representative to make informed decisions regarding care. Findings include:

On 05/02/18 at approximately 1100, Patient (Pt) #1's closed electronic medical record was reviewed with Charge Nurse Staff J. The record indicated Pt #1 was admitted to the behavioral health unit on 03/25/18 and was discharged on 04/25/18. Staff J explained she recalled the patient. She said the patient refused to sign consent for treatment upon admission. Staff J said the patient expressed that she did not want to be hospitalized. Staff J explained the patient at one point refused medication and treatment. Staff J said a petition for mental health treatment was filed and granted per court order on 4/9/2018.

On 05/03/18 at approximately 1000, Patient (Pt) #1's closed medical record was reviewed with the Interim Clinical Manager Staff L and Pharmacist Staff T. The record indicated Pt #1 had been prescribed and administered psychotropic medications, including Risperidone (an antipsychotic medication), Clonazepam (a sedative) and Divalproex (an anticonvulsant) during her stay.

A review of physician's orders dated 3/26/18 through 4/24/18 documented the following medication orders:
Klonopin 1 milligram (mg) by mouth three time per day.
Depakote ER 500 mg by mouth three times per day.
Risperdal 2 mg by mouth two times per day through 3/31/18.
Risperdal 3 mg two times per day beginning 3/31/18 through 4/24/18

A review of the patient's medication administration records (MARS) dated 3/26/18 through 4/9/2018 documented the following:

The patient refused Klonopin on 3/26/18 at 1124 and 1452. The patient was administered Klonopin on 3/26/18 at 2018.

The patient was administered Klonopin on 3/27/18 through 3/31/18 three times per day by mouth. The patient refused Klonopin on 4/1/18 at 0915 and 1414. The patient was administered Klonopin 1 mg on 4/1/18 at 2123. The patient was administered Klonopin 1 mg by mouth three times a day beginning 4/2/18 through 4/8/18.

The patient refused Depakote on 3/26/18 at 1125, 1453 and 2026. The patient refused Depakote on 3/27/18 at 0825 and 1424. The patient was administered Depakote on 3/27/18 at 0935 and 2138.
The patient was administered Depakote on 3/28/18 through 3/30/18 three times per day.
The patient refused Depakote on 3/31/18 at 0840.
The patient refused Depakote on 4/1/18 through 4/2/18 three times per day.
The patient was administered Depakote on 4/3/18 at 0856.
The patient refused Depakote on 4/3/18 at 1412 and 2047.
The patient refused Depakote three times per day on 4/4/18 through 4/9/18.

The patient refused Risperdal 2 mg by mouth on 3/26/18 at 1125 and 2027.
The patient refused Risperdal 2 mg by mouth on 3/27/18 at 0825.
The patient was administered Risperdal 2 mg by mouth on 3/27/18 at 0935 and 2138.
The patient was administered Risperdal 2 mg by mouth two times per day on 3/28/18 through 3/31/18.
The patient refused to take Risperdal 3 mg by mouth per day on 4/1/18 through 4/9/2018.

On 05/04/18 at 1100 an interview and record review was conducted with Medical Director Staff R. Within the record was a form titled, "Consent to Treatment with Psychotropic Medications". dated 3/26/18 at 0941. The form documented the following:

I, a patient of (name of facility) Behavioral Health Services, do hereby give my voluntary consent to receive, the following medication(s):
Depakote, risperdal, klonopin (brand names). However, the form did not contain any documentation or signatures from the patient or patient's representative or clinical staff.

At that time Staff R acknowledged the form titled, "Consent To Receive Psychotropic Medications" should have been signed by the patient (#1) prior to administering the psychotropic medications. Staff R said it was the medical doctor's responsibility to obtain consent for the psychotropic medications before they were administered.

During an interview on 05/03/18 at 1145 Staff L was to provide any further evidence that documented the patient gave consent to be administered the aforementioned medications. Staff L provided a physician's progress note dated 3/27/2018 that documented the patient (#)reported that she took Klonopin and slept better but refused to take the Depakote and Risperdal. Staff L said, there is no consent this all that we have.

The facility policy titled, "Tier 3 Use of Psychotropic Drugs" with a last revision date of 10/11/2017, was reviewed on 05/03/18 at 1235. This policy indicated, under procedure 1,
"Psychotropic medication shall not be administered unless:
a. patient and/or guardian gives informed consent
b. administration is the acceptable treatment for a psychiatric condition
c. court order
d. administration is necessary in an emergency to prevent injury to self of others."