HospitalInspections.org

Based on facility policy review, medical record review and interview, the facility failed to ensure informed consent forms for psychoactive medications were properly executed.

Findings included:

Facility Policy titled, "Psychoactive Medications, emergency use" under the pavilion - nursing department stated in part, "Psychoactive medication will not be administered to a patient without informed consent for the patient or the patient's legally authorized representative unless an emergency exists."

Facility Document titled, "Patient's Bill of Rights" stated in part, "26. You have the right to be told about the care, procedures, and treatment you will be given; the risks, side effects, and benefits of all medications and treatment you will receive, including those that are unusual or experimental, the other treatments that are available, and what may happen if you refuse the treatment."

Texas Administrative Code Chapter 404, Subchapter E titled, "Rights of persons receiving mental health services" stated in part, "(16) The right to be free from unnecessary or excessive medication, which includes the right to give or withhold informed consent to treatment with psychoactive medication ..."

Review of the four out of ten medical records revealed no emergency situations for the psychoactive medications prescribed, however, the consent was unsigned before administration.

Review of patient #1's medical record revealed Ambien 10 mg [milligrams] was administered on 2/27/15 at 11:37 pm and 2/28/15 at 10:51 pm. Consent was not signed until 3/2/15 at 8:15 am.

Review of patient #1's medical record also revealed Depakote 250 mg was ordered twice a day and was administered at the following times before consent was signed:
· 10/6/15 at 3:39 pm
· 10/7/15 at 8:14 am
· 10/7/15 at 8:51 pm
· 10/8/15 at 8:07 pm
Consent was signed on 10/8/15 at 9:20 pm.

Medical record for patient #2 revealed an admission date of 6/10/16. Patient #2 was administered gabapentin 400 mg on 6/11/16 at 5:09 pm. The consent to treatment with psychoactive medication for gabapentin was not signed by the patient #2 until 6/12/16 at 8:00 am.

Medical record for patient #4 revealed an admission date of 5/13/16. Patient #4 was administered Wellbutrin XL [extended release] 300 mg on 5/14/16 at 8:39 am. The consent to treatment with psychoactive medication for Wellbutrin was not signed by the patient #4 until 5/16/16 at 5:15 am.

Medical record for patient #7 revealed an admission date of 6/1/16. Patient #7 was administered lorazepam 1 mg on 6/1/16 at 10:01 am. The consent to treatment with psychoactive medication for lorazepam was not signed by the patient #7 until 6/2/16 at 3:39 pm.

Medical record for patient #10 revealed an admission date of 6/14/16. Patient #10 was administered citalopram 10 mg on 6/15/16 at 9:14 am. The consent to treatment with psychoactive medication for citalopram was not signed at the time of the survey on 6/15/16 at 11:45 am.

The above was confirmed with the director of clinical services on the morning of 6/15/16.