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Based on interview and record review the facility failed to obtain informed consent for the administration of psychotropic medications for 2 of 10 behavioral health patients (#1, #2) out of a total sample of 13 resulting in the withholding of information required by the patient or patients representative to make informed decisions regarding care. Findings include:

On 01/18/18 at approximately 1145, Patient (Pt) #1's closed medical record was reviewed. The record indicated Pt #1 was admitted to the behavioral health unit on 11/03/17 and was discharged on 11/17/17. Further review revealed, during this course of stay, Pt #1 had been prescribed and administered psychotropic medications, including Quetiapine (an antipsychotic medication) and Trazadone (a sedative and antidepressant medication). Within the record was a form titled, "Consent to Receive Psychotropic Medications". This form did not contain any documentation or signatures from the patient or patient's representative or clinical staff. Additional review of the record did not reveal any evidence that Pt #1 or their representative had consented to receive these medications.

During an interview with the Chief Nursing Officer (RN B) and Director of Behavioral Services (RN G) on 11/18/18 at approximately 1200, RN B and RN G acknowledged Pt #1 should have had the form titled, "Consent To Receive Psychotropic Medications" completed.

On 01/17/18 at approximately 1130, Patient (Pt) #2's medical record was reviewed. The record indicated Pt #2 was admitted to the behavioral health unit on 12/27/17 and remained a current patient. Further review revealed, during this course of stay, Pt #2 had been prescribed and administered psychotropic medications, including Clozapine (an antipsychotic medication) and Escitalopram (an antidepressant/antianxiety medication). Within the record was a form titled, "Consent to Receive Psychotropic Medications". This form did not contain any documentation or signatures from the patient or patient's representative or clinical staff. Additional review of the record did not reveal any evidence that Pt #2 or their representative had consented to receive these medications.

During an interview with the Physician (MD J) on 01/17/18 at approximately 1145, MD J acknowledged Pt #2 should have had the form titled, "Consent To Receive Psychotropic Medications" completed. MD J also indicated, due to the severity of the mental illness, Pt #2 was initially unable to consent to receive psychotropic medications, however, Pt #2 had regained the ability to consent approximately 7 days after admission.

The facility policy titled, "Psychotropic Medication" with a last revision date of November 2017, was reviewed on 01/18/18 at 1035. This policy indicated, under procedure 5, "Physician will obtain "Consent to Receive Psychotropic Medication"".