HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 3 rapid responses reviewed of pediatric behavioral health patients (Pt. #11), the hospital failed to ensure that critical care staff responded as required by policy.

Findings include:

1. The hospital's Medical Staff Bylaws (revised November 20, 2024), was reviewed and required, "...Responsibilities of Medical Staff... comply with applicable provisions of ...Hospital policies..."

2. The hospital's policy titled, "Rapid Response Team" (revised 03/01/2025), was reviewed and required, " ...To provide urgent medical assistance and intervention for acute medical problems in the non-critical care patient areas ... The RRT [Rapid Response Team] is composed of the following staff who have expertise in critical care management and principles of resuscitation and can facilitate movement of patients to a higher level of care when needed. 1... 2. Critical Care Resident and/or Critical Care Intensivist ..."

3. The clinical record of Pt. #11 was reviewed on 05/01/2025. Pt. #11 was admitted on 03/01/2025 to the 11th floor Adolescent/Pediatric Behavioral Health Unit, with a diagnosis of aggressive behavior. The record indicated that two rapid responses were called on 03/13/2025, one at 4:39 PM and again at 7:48 PM, both for acute change in condition/seizure-like activity. The record indicated that the rapid response team included a Family Medicine Resident (MD#10); however, lacked documentation that staff from critical care (such as a resident or intensivist) attended/responded to the rapid response.

4. An interview was conducted with ICU (Intensive Care Unit) Nurse Manager (E#12) on 05/01/2025, at approximately 11:00 AM. E#12 stated that when a rapid response is called on the 11th floor (Peds BHU), the expectation is that an ED (emergency department nurse) and ED doctor will go to that unit. E#12 stated that the ICU Charge Nurse and the ICU Resident and/or Intensivist will also respond to the rapid as well.

5. An interview was conducted with Family Resident (MD#10) on 05/01/2025, at approximately 2:00 PM. MD#10 stated that Family Medicine Residents are on-call to respond to all rapid responses throughout the hospital. MD#10 stated that generally on the adult units, ICU will respond to the all rapids; however, for the rapid responses that occurred on the Pediatric Unit on 03/13/2025, MD#10 stated that no resident or attending from ICU responded. MD#10 stated that MD#10 does have PALS (pediatric advanced life support) certification but does not have critical care expertise with pediatric patients.

Based on document review and interview it was determined that for 2 of 3 (Pt.#6 and Pt.#7) clinical records reviewed for informed consent, the hospital failed to obtain consent for treatment and psychotropic medication from the patient to make informed decisions of patient's care.

Findings include:

1. On 04/30/2025, the hospital's policy titled, "Administration of Psychotropic Medication" (revised 10/20/2023) was reviewed and required, "... G. Psychotropic Medication - means medication whose use or antipsychotic, antidepressant, anti-manic, anti-anxiety ...or behavioral management purposes ... III. Required Procedures... 1. Behavioral health patients are provided services pursuant to an individualized treatment plan formulated with the patients... or other person designated by the patient. 2. The physician or designee must advice adult patients... or Guardian... of the right to refuse services including psychotropic medications ... a physician or designee shall advice the patient, in writing of the side effects, risks and benefits of the treatment ... After the written information is provided, it must be noted in the patient's medical record ..."

2. On 04/30/2025, the clinical record of Pt. #6 was reviewed. Pt.#6 was admitted on 04/28/2025, to the hospital's adult medical/psychiatric unit with a diagnosis of aggressive behavior. On 04/30/2025 at 8:52 AM, Zoloft (anti-depressant medication) 100 mg (milligram) tablet was given as a scheduled dose and Brexpiprazole (anti-psychotic medication) 1 mg tablet as a scheduled dose to Pt. #6. The "Department of Psychiatry Medication Consent" form was not completed for Pt. #6 to indicate that the information was provided to Pt.#6 about the medications to make an informed decision.

3. On 04/30/2025, the clinical record of Pt. #7 was reviewed. Pt.#7 was admitted on 04/13/2025 to the adult medical/psychiatric unit with a diagnosis of psychosis (mental disorder) and discharged on 04/28/2025. Pt.#7 received PRN (as needed) haloperidol (anti-psychotic) 5 mg injection on 04/16/2025, 04/17/2025, 04/20/2025, and 04/22/2025. Lorazepam (anti-anxiety medication)1 mg injection PRN on 04/16/2025, 04/17/2025, and 04/22/2025, and risperidone (anti-psychotic medication) 2 mg tablets as a scheduled twice a day on 04/24/2025 through 04/28/2025. The "Department of Psychiatry Medication Consent" form was not completed for Pt. #7 to indicate that the information was provided to Pt.#7 about the medications to make an informed decision.

4. An interview was conducted on 04/30/2025 at approximately 12:20 PM, with Registered Nurse (RN/E#8). E#8 stated that for all patients receiving psychotropic medications, the patient will be informed of reason for medication, desired effects, and side effects. The patients have the right to refuse their medications, which will be documented, and the physician will be notified. The medication consent form is required to be complete and signed by the physician to indicate that the patient was provided education about their medications.