HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt #2) clinical record reviewed for psychotropic medications, the Hospital failed to ensure the patient was educated regarding psychotropic medications.

Findings include:

1. The Hospital's policy entitled, "Consent for Psychotropic Medication Treatment," (dated 3/2017) required, " ...Purpose: To provide patients with instructions concerning the therapeutic indications as well as the potential side effects of psychotropic medications. Procedure: 1. When an order for psychotropic medication is written, it will list the patient's name and medication(s) on a 'Notification of Psychotropic Medication' form ...2. The Registered Nurse ensures that the above procedure is completed ...3. The patient receives written information on the psychotropic medication ...4. The patient must sign the 'Notification Medication' form and have witnessed by the registered nurse."

2. The Clinical record of Pt #2 was reviewed on 5/16/18 at approximately 10:30 AM. Pt #2 was a 23 year old male who was admitted to the Hospital on 3/27/18 with a diagnosis of bipolar disorder. Pt #2's clinical record included documentation that he was admitted involuntarily with an Inpatient Certificate. Pt #2's clinical record contained a physician's orders dated 3/27/18, that required Ativan 2 milligrams (mg) intramuscularly (IM) or by mouth (PO) for severe anxiety/agitation and Haldol 5 mg by mouth (PO) for severe agitation. Pt #2's clinical record contained a "Consent to Medication" form. The form lacked inclusion of the Haldol and Ativan that had been ordered. The form lacked documentation that Pt #2 had been informed by the physician regarding the medications. The form was electronically signed by the physician on 4/2/18 at 3:36 PM (3 days post discharge), and lacked documentation of Pt #2's signature.

Pt #2's clinical record contained a Medication Administration Record that indicated that Pt #2 received Haldol 5 mg IM on 3/28/18 at 10:07 AM, and Ativan 2 mg IM on 3/28/18 and 2 mg PO on 3/29/18 at 1:46 PM and 8:01 PM and again on 3/30/18 at 7:37 AM.

3. The Psychiatric Charge Nurse (E #15) stated during an interview on 5/16/18 at approximately 10:30 AM that the Medication Consent had not been signed by the patient.

4. On 5/17/18, at approximately 2:02 PM, an interview was conducted MD #2. Md #2 stated, "I usually document on my notes or we have a consent form that patients sign ...We never force patients to take medication if they don't want to ..."