HospitalInspections.org

Based on document review and interview, it was determined for 1 of 4 (Pt. #2) records reviewed for psychotropic drugs use, the Hospital failed to ensure the psychotropic education form was completed, to indicate that Pt. #2 was informed and consented to the treatment plan.

Findings include:

1. On 2/7/18 at approximately 11:00 AM, the Hospital's policy titled, "Psychotropic Medication Education" (reviewed 12/17) was reviewed and required, "... Psychotropic medication may include... mood stabilizing drugs...The patient and/or guardian... are to be informed... 1. Why the psychotropic medication is necessary... 2. The probable benefits of the treatment... Completion of Psychotropic Medication Education Form: This form is to be completed by listing the psychotropic medications, date initiated, and must be signed by both the Nurse and the Psychiatrist..."

2. On 2/7/18 at approximately 9:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 48 year old female admitted to the Hospital on 6/23/17 with a diagnosis of schizophrenia. The clinical record included a physician's order for Depakote (mood stabilizer) dated 6/23/17. The clinical record also indicated that Pt. #2 received Depakote on 6/23/17; 6/24/17; 6/25/17; 6/26/17; 6/27/17; 6/28/17; 6/29/17; and 6/30/17. However, the psychotropic education form did not include the name of the psychotropic drug (Depakote), to indicate that Pt. #2 was informed and consented to the treatment plan.

3. On 2/7/18 at approximately 9:25 AM, an interview was conducted with MD #1 (Attending Psychiatrist). MD #1 stated that, "... She (Pt. #2) was on Depakote, which was used as mood stabilizer..."

4. On 2/7/18 at approximately 9:30 AM, findings were discussed with E #3 (Unit Manager, Behavioral Unit). E #3 stated that Depakote is normally included on the Psychotropic Medication Education form to indicate that the patient was informed.

Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed for Advanced Directives, the Hospital failed to ensure information was provided.

Findings include:

1. On 2/6/18 at approximately 3:00 PM, the Hospital's policy titled, "Advance Directives" (reviewed 2/15) was reviewed and required, "... B. All inpatients, their agents or surrogates, as applicable, are given written information on advance directives..."

2. On 2/6/18 at approximately 11:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 49 year old female admitted to the Hospital on 2/4/18 with a diagnosis of psychosis. The clinical record of Pt. #3 did not indicate that information on advance directives was provided.

3. On 2/6/18 at approximately 11:35 AM and on 2/7/18 at approximately 8:45 AM, findings were discussed with E #3. E #3 stated that the area where advance directive was normally documented indicated that information was not provided.

Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed regarding notification of inpatient admission, the Hospital failed to ensure patient's designated individual was notified of the admission.

Findings include:

1. On 2/6/18 at approximately 3:15 PM, the Hospital's policy titled "Patient's Rights and Responsibilities" (revised 2/15/) was reviewed and required, "... The patient and, when appropriate, his or her surrogate have the right to be informed... of their care..."

2. On 2/6/18 at approximately 11:30 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 49 year old female admitted to the Hospital on 2/4/18 with a diagnosis of psychosis. The clinical record of Pt. #3 indicated that a designated person be notified of the admission. However, the clinical record lacked documentation that the designated person was notified of the admission to the Hospital.

3. On 2/6/18 at approximately 11:35 AM and on 2/7/18 at approximately 8:45 AM, findings were discussed with E #3. E #3 stated that the clinical record did not include notification of Pt. #3's designated person.