HospitalInspections.org

Based on review of hospital policies/procedures, hospital documents, medical records, and interviews, it was determined the facility failed to obtain patient signatures on informed consent forms for patients receiving psychotropic medications for 3 of 15 patients (Patients #28, 29 and 30).

Findings include:

Hospital document titled Behavioral Health Client Rights requires: "...A client has the following rights...to give informed consent in writing...."

Hospital policy titled Behavior Health: Informed Consent for Treatment (including Psychotropic Medications) requires: "...Written informed consent is obtained...diagnostic or treatment procedure...and any psychotropic medication...Informed consent forms must be signed by the patient...authorized representative and witnessed by a nurse (or physician)...."

Patient #28 was admitted on 12/30/11 with a history of schizoaffective disorder. The patient was prescribed Zyprexa and Seroquel. There was no informed consent form for the psychotropic medication located in the patient's medical record.

Patient #29 was admitted on 12/12/11 with a history of schizoaffective disorder, alcohol dependence and acute withdrawal, and recent pancreatitis related to alcoholism and Tylenol overdose. The patient was prescribed Zyprexa and Seroquel. There was no informed consent form for the psychotropic medication located in the patient's medical record.

Patient #30 was admitted on 01/06/12 with suicidal ideation, history of fetish behavior, and mental retardation. The patient was prescribed Risperdal. There was no informed consent form for the psychotropic medication located in the patient's medical record.

The Director of Quality and the Senior Clinical Coordinator Manager (employee #8) confirmed during an interview conducted on 01/12/12, that the medical records above did not contain the informed consents required by hospital policy.