HospitalInspections.org

Based on document review and interview, it was determined for 3 of 3 (Pt. #2, #7 and #8) patient on psychotropic medications, the Hospital failed to ensure informed consent was obtained prior to administration of those medications.

Findings include:

1. The Hospital policy titled, "Consent to and Psychotropic Medication Treatment (revised 11/15)" was reviewed on 2/15/17. The policy included, "...if services include the administration of psychotropic medication, the physician shall advise the recipient in writing of the side effects of the education and his right to refuse a psychotropic drug... The registered nurse ensures that the above procedure is completed prior to acknowledging an order for psychotropic medications".

2. The clinical record of Pt. #2 was reviewed on 2/14/17. Pt. #2 was a 24 year old male admitted on 9/4/15 with the diagnosis of Bipolar Disorder with suicidal ideation. A physician's order dated 9/4/15 included, "Cymbalta (antidepressant) 60 mg (milligram) daily and Saphris (antipsychotic) 5 mg every 12 hours...". The Notification of Psychiatric Meds form was left blank for medications; however, had a nurse's signature on the form. Pt. #2 received Cymbalta and Saphris as ordered from 9/4/15 to 9/8/15 (day of discharge) without proper consent.

3. The clinical record of Pt. #7 was reviewed on 2/15/17. Pt. #7 was a 21 year old male admitted on 2/11/17 with the diagnosis of acute psychosis. A physician's order dated 2/13/17 included, "Risperdal (antipsychotic) 1 mg every 12 hours". The Nursing Education Form was left blank for medications; however, had a nurse's and the patient's signature on the form. The Medication Counseling form had the patient's signature, but lacked the physician's signature. Pt. #7 received Risperdal from 2/13/17 to 2/15/17 (date of review) without proper consent.

4. The clinical record of Pt. #8 was reviewed on 2/15/17. Pt. #8 was a 32 year old male admitted on 2/12/17 with the diagnosis of bipolar disorder. A physician's order dated 2/13/17 included, Risperdal 1 mg every 12 hours and Trazadone (antidepressant) 50 mg every night. The Medication Counseling form had the physician's signature, but lacked the patient's signature. Pt. #8 received Risperdal and Trazadone from 2/13/17 to 2/14/17 (date of review) without proper consent.

5. During an interview on 2/15/17 at 1:35 PM, the Director Behavioral Health (E#13) stated, "The consent should be signed before administration of psychotropic medications unless an emergent situation". E#13 stated all of the patients listed should have had consents.