HospitalInspections.org

Based on review of patient care policy, clinical record review, and staff interview, the facility failed to honor the patients right to have a consent signed by the guardian before medications are administered. This affected 1 of 5 (#1) sampled patients.

The findings include:

(1) Review of the current facility policy for informed consent for admission and treatment revealed all patients will be examined within 24 hours to determine the ability to provide express and informed consent. If the person is deemed competent to consent then they may authorize psychotropic medications. If the person is deemed incompetent to sign consent the guardian "may" sign for the medications.

Review of the clinical record for patient #1 revealed at the time of admission on 8/18/10 the patient was examined within 24 hours and found to be incompetent to sign consents for care.

Review of the admission dictation for 8/18/10 by the attending physician revealed patient #1 had a long standing history of bipolar disorder with borderline personality traits. The physician documented that the patient was given Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM as an emergency treatment order earlier that day.
At the time of record review there was no supportive evidence found or provided indicating signed consent was first obtained in accordance with the facility's policy.

Review of the current facility policy for emergency treatment orders revealed the emergency medication order may be utilized when the patient's behavior presents an immediate danger to self or others. The medication order supersedes the individual's right to refuse psychotropic medications. "When the order is initiated for an incapacitated patient the consent in advance of the administration shall be by the guardian or advocate." The physicians order may be by telephone but must be signed within 24 hours. The order is for 24 hours and must be reordered each day that it is needed.

At the time of record review there was no supportive evidence found or provided indicating signed consent was first obtained from the patient's guardian / legal representative in advance of the administration of the medications on 8/18/10. In addition record review disclosed the record does not contain a signed physician's order for the medications administered on 8/18/10 as indicated by the physician's admission note dictation. Furthermore clinical nurse's note document, on 8/21/10 the patient was threatening staff and showing aggressive behavior. The patient was medicated with Haldol 5mg, Ativan 2mg, and Benadryl 50 mg IM at 1545 again based on the pre-existing physician's order of 8/18/10.
As per the policy, the emergency order is for 24 hours and must be reordered each day that it is needed. At the time of record review the clinical record did not contain a signed physician's order for the medications administered to patient 1 on 8/21/10

During an interview on 12/13/10 at 2:00 PM with the director of patient care service for behavioral health, it was confirmed the director is aware the physician / staff failed to obtain and or document consent for the administration of the medications to patient #1 on 8/18/10 from the patient's legal representative, which is not in accordance with the facility's policy. During the interview, the director stated, if the emergency treatment medication order is needed more than one time, the patient's spouse should have been asked to sign the consent and in the case of patient #1 the spouse was not asked to sign consent.

Based on clinical record review and staff interview the facility medical staff and nursing staff failed to ensure physicians orders for the administration of medications are written in accordance with standards of practice and federal regulations at 42 CFR part 482.12(c). This failure affected 1 of 5 (#1) sampled patients.

The findings include:

Review of the admission dictation for 8/18/10 by the attending physician, contained in the clinical record of patient #1, revealed patient #1 has a long standing history of bipolar disorder with borderline personality traits.

The physician's dictation noted, on 08/18/10, patient #1 was given Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM as an emergency treatment order earlier that day. At the time of the clinical record review, the clinical record did not contain a signed physician order for the 3 medications mentioned in the physician's dictation note to have been administered. The nurse recorded the administration of the medications to patient #1 in the Medication Administration Record.

During an interview, on 12/13/10 at 2:00 PM ,with the director of patient care service for behavioral health it was confirmed the director is aware that the clinical record for patient #1 does not contain documentation / signed physician's order for Haldol 5 mg, Ativan 2mg, and Benadryl 50 mg administered on 08/18/10 and the readministration of said medications without signed physician's order to patient #1 on 08/21/10.

Based on clinical record review and staff interview the facility failed to ensure all physicians' orders (including verbal orders) are authenticate with a physicians signature. This failure affected 1 of 5 (#1) sampled patients.

The findings include:

Review of the admission dictation for 8/18/10 by the attending physician, contained in the clinical record of patient #1, revealed patient #1 has a long standing history of bipolar disorder with borderline personality traits.

The physician's dictation noted, on 08/18/10, patient #1 was given Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM as an emergency treatment order earlier that day. At the time of the clinical record review, the clinical record did not contain a signed physician order for the 3 medications mentioned in the physician's dictation note to have been administered. The nurse recorded the administration of the medications to patient #1 in the Medication Administration Record.

During an interview, on 12/13/10 at 2:00 PM ,with the director of patient care service for behavioral health it was confirmed the director is aware that the clinical record for patient #1 does not contain documentation / signed physician's order for Haldol 5 mg, Ativan 2mg, and Benadryl 50 mg administered on 08/18/10 and the readministration of said medications without signed physician's order to patient #1 on 08/21/10 (as evidenced by documentation in the Medication Administration Record).

Based on clinical record review and staff interview the facility failed to ensure the clinical record contains appropriate authenticated physicians orders for medications. In addition nursing staff failed to document medications administered. These failures affected 1 of 5 (#1) sampled patients.

The findings include:

Review of the admission dictation notes for 8/18/10 by the attending physician revealed patient #1 had a long standing history of bipolar disorder with borderline personality traits. The physician dictation notes, the patient was given Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg IM as an emergency treatment order earlier that day.
Record review disclosed the physician failed to sign the verbal orders for the administration of the medications.

During an interview on 12/13/10 at 2:00 PM with the director of patient care service for behavioral health, it was confirmed the director is aware there is no signed physician orders for the medications given to patient #1 as indicated in the physician's dictation. The physician(s) failed to authenticate with their signatures verbal telephone orders.

Review of the seclusion log revealed that on 8/25/10 at 0940 patient #1 was placed in seclusion for 2 hours 28 minutes. The physician failed to document a face to face assessment and did not cosign the telephone order. Continued review of the seclusion log revealed that on 9/1/10 at 0340 patient #1 was placed in seclusion for 1 ? hours. The physician failed to document a face to face assessment and did not cosign the order. The review of the seclusion log also revealed that on 9/4/10 at 1315 patient #1 was placed in seclusion for 4 hours. The physician signed the order and the face to face assessment, however just before the time was up, the physician signed another order extending the seclusion for 4 hours but did not document nor sign a face to face assessment.