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Based on medical record review, staff interview and policy review it was determined the registered nurse failed to notify the health care power of attorney for consent for the administration of newly prescribed psychotropic medications. The registered nurse failed to supervise the behavioral health technicians to ensure activities of daily living were completed as ordered. This affected one ( Patient #10 ) of ten medical records reviewed. The active census on the geropsychiatric unit was 31.

Findings include:


Review of the Informed Consent Policy ID # 1243586 (effective 11/2014) states all patients who have psychotropic medication ordered, and guardian of patients who have a psychotropic medication ordered will be informed of the benefits and risks involved in taking the prescribed medication. Consent to take medications will be given in writing and witnessed by a licensed nurse, physician or pharmacist. Except in emergency situations, informed consent will be obtained prior to administering psychotropic medications.


The nurse is to provide the information to the guardian as given to the patient. When the guardian is not physically available, telephone consent will be obtained. Notation will be made of the medication education sheet. Staff C stated it is the responsibility of the charge nurse to ensure completion of this task.


1. Review of the medical record revealed Patient #10 was a seventy-one year old with increased behaviors of leaving the home and wandering the neighborhood at night. The patient reportedly got lost requiring the local police department to be dispatched to help locate the individual. Once found, the local police notified emergency medical services for further evaluation of the patient's medical/mental status. The medical record revealed the patient was medically cleared by a local hospital and transferred voluntarily by the health care power of attorney to the geropsychiatric unit on 02/19/16 for further evaluation. The patient was discharged from the facility on 02/28/16 per family request.



The medical record revealed the following medications were ordered during the course of the admission. An Exelon Patch (cognition enhancement for dementia) 4.6 mg topically, Depakote (mood stabilizer) 250 mg three times daily, Haldol (antipsychotic) 3 mg intramuscular was administered for agitation, Clonazepam (anti-anxiety) 0.5 mg three times daily and Zyprexa (antipsychotic) 5 mg intramuscular for refusal of by mouth Depakote as ordered.


An informed consent for medications was reviewed with the health care power of attorney upon admission. Several medications were added and/or changed during the course of the admission. The medical record lacked evidence the health care power of attorney was notified per policy prior to the administration of a new prescribed psychotropic medication.

This finding was confirmed with Staff C on 06/21/16 at 2:39 PM.


2. The registered nurse failed to supervise the care provided by the behavioral health technician (BHT). Review of the daily graphics sheets to be completed by the (BHT) lacked evidence the patient received assistance with activities of daily living on 02/26/16. The (BHT) failed to document vital signs, tilting schedule, intake/output, and assistance with activities of daily living including bathing, pericare, and oral care.

This finding was confirmed with Staff C on 06/21/16 at 2:39 PM. Staff C stated the expectation of the (BHT) is to document and the registered nurse supervise all care provided.