HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to comply with a verbally rescinded consent to administer two psychoactive medications for Patient #1 by her legally authorized representative. Patient #1 continued to receive these medications after consent was apparently rescinded. In addition, consent for these medications was not obtained initially according to facility policy.

Findings were:

Facility policy entitled Plan of Operation, review date January 2015, revealed the following:
"A. Treatment Modalities ...
7. Medication - Physicians prescribe medications for patients who have been assessed and judged to meet the criteria for respective medication ...Patient education is provided and consent is obtained prior to the use of the medication ..."

Facility policy entitled Informed Consent for Psychoactive Medication, review date January 2015, revealed the following:
"II. POLICY ...
The procedures used to obtain consent will be in accordance with the most current regulations in the Texas Administrative Code, under the chapters governed by the Texas Department of State Health Services ...
III. PROCEDURES
B. Verbal consent can be obtained via phone in order to prevent treatment delays. Staff should document that the informed consent was obtained via phone with the following process: ...
4. Second licensed personnel (RN, LVN, or physician) should then confirm consent ...
6. Both nurse and witness are to sign consent and place original in chart to be scanned into medical records ..."

Review of the clinical record of Patient #1 revealed she was a 9-year-old patient. Consents were given for Abilify, Lexapro and Trileptal -- all psychoactive medications -- via telephone by the mother of Patient #1 on 4/11/17, no time noted. The consents were signed by only one RN; i.e., there was no witness to the consents.

In addition, the clinical record of Patient #1 included a nursing note which stated "Parent/Guardian refused" for evening doses of Trileptal and Abilify on 4/12/17 at 8:00 p.m. There was no indication of whether the parent had refused one dose or was permanently rescinding consent for the medications. The doses of Trileptal and Abilify were then administered to Patient #1 at 9:33 p.m. on 4/12/17. There was no documented evidence in the record of Patient #1 that her mother had changed her mind to allow the medications to be administered. The two medications continued to be administered to Patient #1 throughout her stay until discharge on 4/14/17.

In a telephone interview with the mother of Patient #1 on the morning of 7/11/17 at 8:22 a.m., she stated, "We weren't familiar with the medications...I was doing research on them at home."

When reviewing the medication administration record, Staff #2, Nurse Manager, agreed the nursing documentation did not provide adequate information to ascertain the wishes of the mother of Patient #1 regarding her medication. "It looks like her mother didn't want her to have the medication, but it's not clear whether that was just that time or that night or what. It's not clear that she wanted her to continue to have it at all." She also stated the psychoactive medication consents obtained via telephone for the patient should have two staff signatures. "I agree, there should be a witness signing on these. That would be our policy."

Based on a review of facility documentation and staff interview, the facility failed to ensure a medical history and physical examination was completed on each patient by an privileged medical staff member according to facility policy. This deficiency was found in 2 of 10 patient records reviewed [Patients #2 and #7].

Findings were:

Hospital policy entitled Plan of Operation, review date January 2015, included the following:
"History & Physical
A medical history and physical examination shall be the responsibility of the attending physician or designee. In all cases, the physical examination will be completed within 24 hours of admission ...

A review of the medical record of Patient #2 revealed he was admitted on 5/22/17. The history and physical examination form for this 5/22/17 admission only referred to a history and physical examination from a previous admission. The form included the statement: "No changes to previous history and physical dated 5/2/17." When the history and physical examination of 5/2/17 was found, it included only the statement, "No changes to previous history and physical dated 4/14/17." Thus, the medical record of Patient #2 did not include an up-to-date history and physical examination.

A review of the medical record of Patient #7 revealed she was admitted to Metroplex Hospital on 6/11/17 and discharged on 6/16/17. The record included only a history and physical examination completed on 5/12/17.

The above findings were confirmed by Staff #2, Nurse Manager, during a review of medical records on the afternoon of 7/11/17 in an office of the psychiatric unit of the hospital. They were again confirmed in an interview with the Director of Behavioral Health and the Risk/Compliance Manager on the afternoon of 7/11/17 in the office of the Director of Behavioral Health.

Based on a review of facility documentation and staff interview, the facility failed to ensure a process to convey the dietary intake observed by nursing staff was conveyed to the appropriate medical personnel in a timely manner for 1 of 1 patients [Patient #1] who was not eating.

Findings were:

A review of the medical record of Patient #1 revealed the following documentation regarding percentages of meals consumed at the facility:

4/10/17 - 50% dinner, 100% evening snack
4/11/17 - 100% dinner, 100% evening snack
4/12/17 - 25% breakfast, 0% lunch, 0% evening snack
4/13/17 - 0% breakfast, 0% lunch, 0% dinner, 0% evening snack
4/14/17 - 0% breakfast, 0% lunch (note: "emesis, gagging")

The medical record contained numerous progress notes which included documentation that the patient reported feeling dizzy and nauseated.

In an interview with Staff #4, RN on the children's psychiatric unit, on the afternoon of 7/11/17 in a hospital office, she was asked about the meal percentages eaten and documented for Patient #1, and if that information was passed on to medical providers at the facility. She stated, "Just because it says 0% for her [Patient #1] on some meals, that doesn't mean she didn't eat anything. There's a span there...from 0% to 25%. She might have eaten something. We really don't know...I'm not sure how that information got passed on."

In an interview with Staff #2, Nurse Manager, on the afternoon of 7/11/17 in an office of the psychiatric unit of the hospital, she was asked how this information was conveyed to medical staff responsible for the physical assessment of the patient. She stated the facility had no policy regarding this matter.

A Psychiatric Consultation dictated by a nurse practitioner on 4/14/17 at 5:36 p.m. was identified by the Nurse Manager as one of two medical assessments Patient #1 received. The other medical assessment was performed on 4/11/17 at 6:08 p.m. and was her admission history and physical. The 4/14/17 noted included the following:
"History of Present Illness:
For the last 2 days, patient has been complaining of dizziness with nausea with thoughts that it may have been because of her Abilify. Patient was taken off the medication. Patient did not improve. Patient denies having any pain. She just says she does not feel well. The nurse reported that she did throw up this morning. After examining her, I talked with the parents. The mom reports that the patient actually responds like this whenever she tries new medications, and in the past, she has required Zofran for a few days along with the new medication. Patient has been crying a lot. She has been walking unsteadily, and she is talking very little. She is not eating very much ...
Physical Examination: ...
Patient appears to not feel well. She does have an unsteady gait and puts her hands about her as if trying to steady herself as she walks or sits. She is speaking very little. Answers some questions. She is crying a lot through the exam, although she has no tears. She appears to be trying to build up her emotions, but she does seem to appear not [to] feel well ...
Laboratory Data:
Laboratory on admit was normal, but we have ordered labs today, which are not yet available.
Diagnoses:
Dizziness with nausea ..."

The above findings were confirmed with Staff #2, Nurse Manager, during a review of the medical record of Patient #1 on the morning of 7/11/17 in an office of the psychiatric unit of Metroplex Hospital.