HospitalInspections.org

Based on record review and interview the facility failed to ensure patient was involved in making informed of decisions regarding his or her care by failing to follow the company's policy on patients informed consents for medications and failing to inform patients of risks of leaving the facility against medical advice (AMA) for 1 (P(patient)1) out of 3 (P1-P3) patients being reviewed . This deficient practice could possibly lead to a violation of a patients right to refuse care.

The findings are:

Failed to ensure that a patient was involved in care planning:

A. Record review of the facility's policy titled "Medication Administration and Process" dated as revised on 12/2023, under section 6.1 stated "All patients, and/or legal guardians, prescribed a psychotropic medication will be informed of the benefits and risks involved in receiving the prescribed medication."
-Under the section 6.2 stated " . . .informed consent will be obtained prior to administering psychotropic medication". -Section 6.5 stated "Medications requiring informed consent: Psychotropic medications . . ."
-Section 6.6 stated "The nurse will obtain and witness the patient's or the legal guardian's written consent to the prescribed medication . . . "

B. Record review of P1's medical record revealed the following:
- On the form titled Chart Summary revealed P1 was admitted on 05/30/24.
-Provider's note under "Medications" revealed "Fluoxetine 80 mg p.o. at bedtime . . . Abilify 5 mg -p.o." The note also stated "The patient refused even to sign the consent form."
-The form titled "physician orders" dated 05/31/24 stated to dispense the first dose of Abilify. Indicating for the nurse to dispense the first dispense
-The section MAR revealed that P1 was offered the Abilify and the Fluoxetine twice. The fluoxetine was administered on 05/31/24 at 20:42 (8:42 PM) and the Abilify was offered on 05/31/24 at 12:41 PM and on 06/01/24 at 9:42 PM despite the patient's initial refusal.
- The record did not contain any evidence of a consent for the medication in P1's medical chart for the Abilify and Fluoxetine. The record did not contain any evidence that P1 was educated on the risks and benefits of the Fluoxetine.

C. During an interview with S2,clinical administrative staff member on 11/05/24 at 3:45 PM, when asked if a written informed consent is needed for psychotropic medications. S2 confirmed that written informed consent is required for all psychotropic medications. When asked if Abilify and Fluoxetine are considered psychotropic medications. S2 confirmed that they are both considered psychotropic medications. When asked when written consent should be obtained. S2 stated "Prior to the first administration of the medication". When asked what happens when the patient refuses to sign the consent form S2 explained that the medication will not be administered.

Failed to ensure that P1 was able to make informed decisions when leaving AMA:

D. Record review of the facility's policy titled "Request for Discharge Against Medical Advice (AMA)" stated "It is the policy of [name of facility] to insist that clients and families be made aware of the relative risks versus benefits of discontinuing treatment prematurely and against medical advice. . ."

E. Record review of the P1's medical record revealed the following:
-The form titled Chart Summary revealed P1 was admitted on 05/30/24.
- On 06/01/24, P1 requested to leave the facility against medical advice.
- The document titled "Request for AMA Discharge" revealed the risks versus benefits were not documented on the form.
- Provider note dated 06/01/24, stated "she has elected to sign out against medical advice." The record not did not contain any evidence of any attempts to inform the patient or the patients family of any of the risks versus benefits in regards to leaving the facility against medical advice.

F. During an interview with P1's family member on 11/05/24 at 1:50 PM, she confirmed that she was not informed of the risks versus benefits of P1 leaving the facility.

G. During an interview with S2, clinical administrative staff member, on 11/14/24 at 3:45 PM S2 confirmed that there was no evidence that the patient was informed of the risks versus benefits of signing out AMA.