HospitalInspections.org

Based on document review and interview it was determined that for 1 (Pt. #4) of 9 clinical records reviewed for psychotropic medication consent, the hospital failed to ensure the informed consent was obtained prior to medication administration.

Findings include:

1. On 11/09/2021, at approximately 2:00 PM, the Hospital's policy titled, "Informed Consent for Medication" dated 11/2014 was reviewed and included, " ...Informed consent for the administration of psychoactive medication shall be required for all patients, voluntary or involuntary ...such consent must be written and made a part of the medical record ..."

2. On 11/09/2021 at approximately 12:30 PM, Pt. #4's clinical record was reviewed. Pt. #4 was admitted to 3 South - Adult Open Unit on 11/07/2021 at 3:52 AM, with a diagnosis of major depression.

Pt. #4's clinical record included the physician's order dated 11/07/2021 at 11:23 AM, to administer Zoloft (anti-depressant) 100 mg (milligram) daily PO (per orally). Pt. #4's medication administration record indicated the administration of Zoloft medication by the Registered Nurse (RN) /E #7 on 11/08/2021 at 8:07 AM and on 11/09/2021 at 9:24 AM. Pt. #4's clinical record lacked the documentation that informed consent was obtained prior to the administration of the psychotropic medication.

3. On 11/09/2021 at approximately 12:35 PM, the RN (E #7) on 3 South Unit was interviewed. E #7 stated that there should have been a medication consent since it's patient right.