HospitalInspections.org

Based on record review and interview, nursing staff failed to ensure the rights of 6 out of 10 current and discharged patients (Patients #2, #3, #5, #8, #9, #10) to make informed decisions regarding their care and to be involved in treatment in that medication consents of psychoactive medications were not obtained prior the the patients receiving their first dose of medication.

Findings included:

Patient #2's Demographic Profile noted a patient admission date of 02/24/15 at 22:00. Admitting diagnoses included Depressive Disorder. Xanax 0.25 milligram (mg) by mouth was administered on 02/26/15 at 12:15 and at 14:00. The Consent to Treat with Psychoactive Medication for Xanax was signed by Patient #2 on 02/28/15 at 18:57, approximately fifty-three hours after the initial dose of Xanax.

Patient #3's Psychiatric Evaluation noted a patient admission date of 02/28/15. Patient #3's diagnoses included Major Depressive Disorder, Severe, with Suicidal Ideation. On 03/01/15 at 20:30, Patient #3 received Ativan 0.5 mg by mouth for Anxiety. The Consent to Treat with Psychoactive Medication for administration of Ativan was signed by Patient #3 forty-six hours later on 03/03/15 at 18:30.

Patient #5's Psychiatric Evaluation dated the admission to 03/02/15. Diagnoses included Major Depressive Disorder, Severe. Physician's Orders dated 03/03/15 at 10:00 reflected Venlafaxine 75 mg was ordered daily for mood stabilization and Ativan 1 mg was ordered twice daily as needed for Anxiety. Patient #5 received Venlafaxine (Effexor) 75 mg on 03/04/15 at 09:00 and on 03/05/15 at 09:00. Ativan 1 mg was administered on 03/05/15 at 18:25. Risperidone 1 mg was physician ordered on 03/05/15 at 12:00 to be administered once daily at bedtime for psychosis. Patient #5 received Risperidone (Risperdal) 1 mg by mouth on 03/05/15 at 18:00. There was no evidence of medication consents for Effexor, Ativan, or Risperdal in Patient #5's chart. Hospital Personnel #2 stated on 03/06/15 at 14:30 that she could not find medication consents signed by Patient #5.

Patient #8's Physician Discharge Summary noted an admission date of 08/21/14 and a discharge date of 08/27/14. Diagnoses included Major Depressive Disorder, Generalized Anxiety Disorder, and Post Traumatic Stress Disorder (PTSD). Patient #8's Medication Administration Record (MAR) noted Restoril (Temazepam) 30 mg was administered on the day of admission, on 08/21/14 at 21:00. Ativan was administered "per detox protocol" on 08/21/14 at 23:00 and on 08/22/14 at 07:00, 13:00, and 19:00. Venlafaxine (Effexor) 225 mg was administered on 08/22/14 at 09:00. Consents to Treat Ativan, Restoril, and Effexor were signed by Patient #8 on 08/23/14.


Patient #9's Medication Administration Record dated 01/23/15 noted Patient #9 received Quetiapine (Seroquel) 200 mg tablet by mouth on 01/23/15 at 09:00 and 18:00. Patient #9 received Seroquel 100 mg tablet on 01/24/15 at 21:00. Patient #9's Consent to Treat with Psychoactive Medication Consent form was faxed to the surveyor on 03/10/15. It was dated as signed on 03/06/15, the date of survey. Hospital Personnel #2 stated during a telephone interview on 03/10/15 around 13:00 that the medication consent for Seroquel was dated on 03/06/15.

Patient #10's Physician Discharge Summary noted Patient #10 was admitted to the hospital on 08/07/14 and discharged on 08/29/14. Discharge Diagnoses included Bipolar Depression. Patient #10's MAR dated 08/07/14 noted the patient received Deparkote Sprinkles 125 mg at 09:00 and at 18:00. The patient received Seroquel 25 mg at 21:00. The Consents to Treat with Psychoactive Medications for Depakote and Seroquel were signed by Patient #10 on 08/12/14, five days after the initial doses were administered. Patient #10 received Cymbalta on 08/14/14 at 09:00. The MAR noted that consent had not been obtained. The Consent to Treat with Cymbalta was signed on 08/14/14 at 14:00, five hours after Patient #10 received the morning dose of Cymbalta.

Hospital Policy BH-019 dated 10/02/12 noted that "Nursing staff are to assure that the informed consent process, and all relevant documentation for each class of psychoactive medication prescribed, have been completed prior to administration of the first dose of psychoactive medication...If patient lacks the capacity to give informed consent or refuses to sign the documentation...psychoactive medications will not be administered until such time as the patient...agrees to sign the consent documentation..."

Hospital Personnel #2 acknowledged on 03/06/15 around 17:00 that patients' consent signatures for psychotropic medications had not been obtained.