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AURORA CHICAGO LAKESHORE HOSPITAL
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on document review and interview, it was determined for 2 of 5 psychotropic drug record reviewed (Pt #'s 5 and 6), the Hospital failed to ensure that consent to psychotropic medication was completed as required.
Findings include:
1. On 6/23/16, the Hospital policy titled "Psychotropic Medication Informed Consent" (revised 10/15) indicated, "... For each medication ordered for administration to the patient, The Physician or Physician's designee advises the recipient (patient), in writing, the following: benefits of treatment, the risks of treatment, the side effects of treatment, alternatives to the proposed treatment... Procedure: Adult Units: The transcribing RN list the date and name of each psychotropic medication separately on the Psychotropic Medication Informed Consent Form... The Psychotropic Medication Informed Consent form is placed in the front of the Physicians Orders for the physician to sign after reviewing with the patient..."
2. On 6/23/16, the clinical record of Pt. #5 was reviewed. Pt. #5 was a 35 year old male patient admitted on 6/21/16 with a diagnosis of Opiate Use and Bipolar Disorder. Pt. #5 had a physician's order of Seroquel (antipsychotic) on 6/22/16. Pt. #5 received the Seroquel on 6/22/16 at 1:00 PM. However, Pt. #5's Psychotropic Medication Informed Consent Form did not include Seroquel.
3. On 6/23/16, the clinical record of Pt. #6 was reviewed. Pt. #6 was a 40 year old female admitted on 6/10/16 with a diagnosis of Bipolar Panic Disorder. Pt. #6 had a physician's order on 6/11/16 for Depakote (mood stabilizer), 6/11/16 for Prolixin (antipsychotic), and on 6/20/16 for Effexor (antidepressant). Per medication administration sheet, Pt. #6 received the medications. However, Pt. #6's clinical record contained a blank Psychotropic Medication Informed Consent Form. Therefore, Pt. #6 was given the medications without her consent.
4. On 6/23/16 at approximately 2:00 PM, findings were discussed with the Chief Nursing Officer who stated that the Psychotropic Drug Consent should have been completed.