HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 10 (Pt. #3 and Pt. #4) clinical record reviewed for antipsychotic medications, the Hospital failed to ensure consents for psychotropic medications were obtained.

Findings include:

1. Policy entitled "Psychotropic Medications" (effective 5/14) indicated "Procedures(s): The attending physician: 1. Informs the adult patient about medication ordered and completes the Medication Consent Form with the patient. 1. Provided the patient does not object, the physician may obtain consent and inform the patient(s) active legal guardian or durable power of attorney. 3. The Registered Nurse administering medication checks that the Medication Consent Form is completed prior to giving the medication."

2. On 12/22/16 at approximately 3:00 PM the form entitled "Medication Consent Form" was reviewed. This form indicated "Acknowledgement: My signature confirms that during the course of the hospitalization the indications, benefits, risks and alternative options for the use of each medication have been discussed with the patient..." This form has an allotted space for the signature of the physician, patient and Registered Nurse.

3. On 12/22/16 at approximately 3:00 PM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 44 year old male admitted to the Behavioral Health Unit (BHU) on 12/17/16 with a diagnosis of suicidal ideation. Pt. #3's record contained a physician's order dated 12/17/16 at 12:00 PM for Seroquel 100 milligrams (mg) daily. Pt. #3's electronic medication administration report (eMAR) was reviewed from 12/17/16 thru 12/19/16 Pt. #3 received a dose of Seroquel on 12/17/16 at 11:43 AM; 12/18/16 at 1:05 PM and 12/19/16 at 11:46 AM.

Pt. #3's clinical record contained a "Medication Consent" 12/17/16 for the following medication: Ambien (sedative), Ativan (anti-anxiety), Haldol (antipsychotic). The clinical record lacked consent for Seroquel (antipsychotic).

4. On 12/22/16 at approximately 3:15 PM the clinical record of Pt. #4 was reviewed. Pt. #4 was a 30 year old male admitted to BHU on 12/18/16 with a diagnosis of schizoaffective disorder. Pt. #4's clinical record contained a physician's order dated 12/18/16 for Geodon (antipsychotic) 40 mg twice a day. Pt. #4's eMAR from 12/18/16 thru 12/22/16 was reviewed. Pt. #4's was administered a dose of Geodon on the following days: 12/18/16 at 5:32 PM; 12/19/16 at 8:41 PM and 5:19 PM; 12/20/16 at 8:21 AM and 4:24 PM; 12/21/16 at 8:58 AM and 5:33 PM; 12/22/16 at 8:20 AM.

Pt. #4's clinical record contained a "Medication Consent" dated 12/18/16 for the following medication: Ambien, Ativan and Prolixin. This consent failed to include consent for Geodon.

5. On 12/23/16 at approximately 8:15 AM the aforementioned findings were discussed with the Manager of Behavioral Health Medicine (E #2). E #2 stated it is the physician's responsibility to obtain the consent from the patient and the nurse should verify before administering the medication.