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Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to protect and promote each patient's rights as evidenced by: failure to obtain consent from the patient before the administration of psychotropic medication (A0117) and failure to provide proper staff supervision (A0144).

Cross Reference:
482.13(a)(1) Patients Rights: Notice of Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on facility policy and document review, medical record review (MR), and staff interview, it was determined that the facility failed to obtain consent from the patient or the patient's representative before the administration of psychotropic medication in 5 of 5 adolescent patients (Patient #1, #2, #3, #4, #5) sampled. Findings include:

Facility policy "Informed Consent for Psychotropic Medications" issued January 2019 and reviewed January 2024, revealed, "...Informed consent must be obtained by the physician...Consent will be documented on a medication consent form with signatures of both the patient/guardian, the physician or in the electronic HCS [electronic health system] system...No medication can be administered without consent..."

Review of MR1 revealed:

"Physician Medication Orders" documents the following psychotropic medications were ordered on 9/16/24:
- divalproex sodium DRT [delayed release tablet] 500 mg (milligrams) by mouth at bedtime for mood stabilization.
- hydroxyzine pamoate 25 mg by mouth four times a days needed for anxiety.
- trazodone 50 mg by mouth at bedtime as needed for sleep.
- divalproex 250 mg DR [delayed release] by mouth every morning for mood stabilization.

"Medication Administration Record" revealed patient received:
- divalproex sodium DRT 500 mg on 9/16/24 at 10:08 PM.
- hydroxyzine pamoate 25 mg on 9/19/24 at 5:30 PM.
- trazodone 50 mg on 9/17/24 at 10:43 PM.
- divalproex 250 mg DR on 9/17/24 at 8:51 AM.

There was no evidence of patient consent for these psychotropic medications.

Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS (Electronic health system). These findings were confirmed with EMP4 on 9/24/24 at 10:39 AM.

Review of MR2 revealed:

"Physician Medication Orders" documents the following psychotropic medications were ordered on 5/16/24:
- lamotrigine 200 mg by mouth daily for mood stabilization.
- fluoxetine 40 mg by mouth daily for mood stabilization.
- hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety.
- guanfacine extended release 2 mg by mouth daily at bedtime for mood stabilization.

"Medication Administration Record" revealed patient received:
- lamotrigine 200 mg on 5/19/24 at 9:49 AM.
- fluoxetine 40 mg on 5/18/24 at 12:29 PM.
- hydroxyzine pamoate 25 mg on 5/19/24 at 00:10 AM.
- guanfacine extended release 2 mg on 5/17/24 at 9:33 PM.

Interview with EMP4 on 9/23/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/23/24 at 1:45 PM.

Review of MR3 revealed:

"Physician Medication Orders" documents the following psychotropic medications were ordered on 9/10/24:
- hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety.
- guanfacine extended release 1 mg by mouth daily for mood stabilization.

"Medication Administration Record" patient received:
- hydroxyzine pamoate 25 mg on 9/10/24 at 8:01 PM.
- guanfacine extended release 1 mg on 9/11/24 at 8:36 AM.

Interview with EMP4 on 9/23/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/23/24 at 1:45 PM.

Review of MR4 revealed:

"Physician Medication Orders" documents the following psychotropic medications were ordered on 8/8/24:
- hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety.
"Physician Medication Orders" documents the following psychotropic medications were ordered on 8/12/24:
- guanfacine extended release 2 mg by mouth daily for mood stabilization.
- risperidone 1 mg by mouth twice a day for mood stabilization.
"Physician Medication Orders" documents the following psychotropic medications were ordered on 8/16/24:
- chloropromazine 50 mg by mouth every 6 hours as needed for agitation.

"Medication Administration Record" patient received:
- hydroxyzine pamoate 25 mg on 8/8/24 at 8:25 PM.
- guanfacine extended release 2 mg on 8/13/24 at 9:17 AM.
- risperidone 1 mg on 8/12/24 at 5:24 PM.
- chloropromazine 50 mg on 8/16/24 at 1:39 PM.

Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/24/24 at 10:30 AM.

Review of MR5 revealed:

"Physician Medication Orders" documents the following psychotropic medications were ordered on 7/16/24:
- hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety.
"Physician Medication Orders" documents the following psychotropic medications were ordered on 7/24/24:
- chloropromazine 50 mg by mouth every 6 hours as needed for agitation.
- diphenhydramine 50 mg by mouth every 6 hours as needed for aggression.
"Physician Medication Orders" documents the following psychotropic medications were ordered on 7/28/24:
- quetiapine 50 mg by mouth twice a day for mood stabilization.

"Medication Administration Record" patient received:
- hydroxyzine pamoate 25 mg on 8/3/24 at 8:08 PM.
- chloropromazine 50 mg on 8/9/24 at 1:52 PM.
- diphenhydramine 50 mg on 8/2/24 at 4:52 PM.
- quetiapine 100 mg on 8/2/24 at 12:58 PM

Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/24/24 at 10:37 AM.

Based on review of facility policies and medical records (MR), it was determined that for 1 of 7 patients (Patient #3) sampled, the facility failed to provide proper staff supervision as evidenced by missed safety observation checks. Findings include:

Review of facility policy "Patient Observation" issued on 3/3/08 and revised 3/24 revealed, "To ensure patient safety ...observe each patient, a minimum within every 15 minutes ...Document patient location and behavior ..."

Review of MR3's "Ancillary Orders" dated 9/10/24 at 11:24 AM documented an order for every 15-minute level of observations.

Review of MR3's "Patient Observation Record" revealed no evidence patient was observed on 9/10/24 from 12:00 midnight to 11:30 AM for 47 missed safety checks.

EMP12 confirmed this finding on 9/23/24 at 2:40 PM.

Based on medical record review (MR), policy review, and staff interview, it was determined that for 5 of 7 (Patient #2, #3, #4, #5, and #6) patients, the facility failed to ensure nursing staff followed facility policies as evidenced by failure to completed blood glucose checks as ordered, failure to report abnormal blood sugar readings to the physician/designee or licensed independent practitioner, and failure to sign medical record entries. Findings include:

I. Blood sugar monitoring

Review of facility policy "Diabetic Care" revised January 2019 and reviewed January 2024, revealed, "...Blood glucose levels will be tested at the frequency ordered by the physician...The level will be recorded in the patient's medical record..."

Review of facility job description "Registered Nurse" job code 650 revealed, "...Responsibilities...Performs treatments...as ordered by physician..."

Review of MR6 medical record revealed:

"Final Ancillary Orders (non-med)" dated 8/12/24 at 4:30 PM documented an order for blood glucose (sugar) monitoring before meals and at bedtime. 

"All Observations Recorded During the Stay" revealed no evidence of documentation of 12 out of 29 blood sugar monitoring scheduled from 8/12/24 to 8/19/24.

EMP3 confirmed the finding on 9/23/24 at 1:36 PM.


II. Nursing progress notes

Review of facility policy "Medical Record Documentation Requirements" issued 12/96 revealed, "Documentation of patient care...Entries shall be dated, timed, and signed..."

a. Review of MR2's nursing progress notes revealed a typed note dated 9/7/24 at 6:00 PM and without a signature and a note dated 9/19/24 without a time or signature.

EMP4 confirmed the finding on 9/23/24 at 3:25 PM.

b. Review of MR3's nursing progress notes revealed a typed note dated 9/19/24 without a time or signature.

EMP4 confirmed this finding on 9/23/24 at 1:45 PM.

c. Review of MR4's nursing progress notes revealed a typed note dated 9/19/24 without a time or signature.

EMP4 confirmed this finding on 9/24/24 at 10:30 AM.

d. Review of MR5's nursing progress notes revealed a typed note dated 9/19/24 without a time or signature.

EMP4 confirmed this finding on 9/24/24 at 10:37 AM.