HospitalInspections.org

Based on record review and interview the hospital failed to ensure the right of one of one patient (Patient #1) and/or her representative to make informed decisions regarding Patient #1's care. Patient #1, a minor, received two doses of increased medication without the representative's consent.


Findings included:


Patient #1's Physician's Order Sheet dated 08/03/16 at 1400 reflected to increase Patient #1's Abilify medication (antipsychotic medication) to 5 milligrams by mouth at night.

Patient #1's Interdisciplinary Progress Note dated 08/04/16 at 1954 reflected Patient #1's representative "...called and informed the nurse that the Patient's Abilify should not be increased from 2.5 milligram..."

The hospital Medication Administration Record dated 08/03/16 at 2100 and 08/04/16 at 2100 reflected Patient #1 received Abilify 5 milligrams.

The Medical Administration Record dated 08/05/16 reflected Patient #1's representative refused consent and wanted the dose to be 2.5 milligrams.

During a telephone interview on 09/08/16 at 15:39 Personnel #4 stated that "it was a medication error on our part if ...[Patient #1] did not receive the medication of 2.5 milligrams of Abilify and received the 5 milligrams."

The hospital policy titled Medication Administration Inpatient or Day Patient Record, dated 08/2015 reflected, "The facility shall define and approve licensed independent practitioners and the clinical staff disciplines that are authorized to administer medications...double check the order..."