HospitalInspections.org

Based on record review and interview, the facility failed to ensure that medications were administered as ordered by the practitioner by failing to obtain informed consent for the administration of the medications in a timely manner for 2 (#1, #4) of 5 (#1, 2, 3, 4, 5) sampled patients reviewed for medication administration.

Findings:

Patient #1

Review of the medical record revealed a 14 year old male was admitted with diagnoses including Major Depressive Disorder, Suicidal Ideation and Anxiety.

Review of the Initial Nursing Assessment dated 4/14/21 at 1:15 p.m. revealed home medications included Lexapro (antidepressant) 10mg po daily and Abilify (antipsychotic) 10mg po daily.

Review of the Psychiatric Evaluation dated 4/15/21 at 9:24 a.m. confirmed home medications included Lexapro 10mg po daily and Abilify 10mg po daily. The estimated length of stay was anticipated to be 5-7 days. The Treatment plan included:
1. Symptom stabilization, diagnostic clarification, appropriate disposition planning;
2. Resume home meds with changes;
3. Change: Lexapro 10mg po daily to Lexapro 20mg daily;
4. Buspar 5mg po bid;
5. Trileptal 150mg po qhs;
6. Monitor closely for psychiatric symptoms that warrant pharmacological intervention;

Review of the Physician Orders revealed the following:
4/15/21 9:42 a.m. - Lexapro 20mg po daily; Buspar 5mg po bid; Trileptal 150mg po qhs - obtain consent before use.
4/18/21 9:00 a.m. - please begin meds today due to unable to contact for consent (ORDER CANCELLED GOT IN CONTACT WITH FATHER LEGAL GUARDIAN);

Review of the Physician Progress notes revealed the following notations:
4/16/21 - patient reported family contact was positive
4/17/21 - patient reports he hasn't had any meds since he has been here
4/18/21 - informed patient that consent has not been obtained for his meds

Review of the Medication Administration Record revealed the following:
On 4/15/21, orders were noted for Lexapro 20mg po qd, Buspar 5mg po bid, Trileptal 150mg po q hs. Medications were documented as "not given due to no consent" until the 4/18/21 8:00 p.m. doses of Buspar and Trileptal.

Review of the Informed Consent Form revealed the following attempts documented by nursing for Lexapro 20mg po daily; Buspar 5mg po bid, Trileptal 150mg q hs:
4/16/21 6:59 p.m. (busy line) - S2LPN;
4/17/21 4:57 p.m. (phone cannot receive calls) - S2LPN
4/17/21 (no time documented - line busy) - S3LPN
4/18/21 11:57 a.m. consent obtained from father by S4LPN
Further review of the consent form revealed one phone number was noted that had been scratched out and a second number documented as the number used to make contact on the final attempt by S4 LPN.

Review of the List of Contacts sent from the transferring hospital for patient #1 revealed 4 available contacts with 4 different phone numbers were provided.

Review of the Therapy Notes revealed the following family contacts were made:
On 4/15/21 at 12:26 p.m., the therapist made contact with the patient's mother to discuss the patient's care plan.
On 4/16/21 the therapist conducted a family therapy session by phone with the mother of patient #1 - patient reported he has not started medications yet.
On 4/19/21 the therapist had phone contact with mother, who expressed concern that the patient has not started medications (therapist looked up progress notes and saw nurses never gained consent). Mother said that she was not contacted to provide consent. Mother was transferred to nurse's station.

On 06/08/21 at 10:15 a.m., an interview with S5 LPN, Floor Nurse revealed that home meds should be reconciled and confirmed by the registered nurse with family, physician or the pharmacy during the admission process, and contact should be made within 24 hours with parent/guardian to get informed consent for medications ordered by the physician.

On 06/10/21 at 11:20 a.m., an interview with S2LPN confirmed she had attempted contact with the guardian of patient #1 on 04/16/21 at 6:59 p.m. and 04/17/21 at 4:57 p.m. She confirmed that she only tried the one contact number that was on the consent form and did not attempt to find alternate contact numbers. She stated the nurses will usually ask the child to get the current phone number for them when they have their evening phone calls with family, but did not recall if that was done in this case.

On 06/10/21 at 11:25 a.m., an interview with S3LPN confirmed she had attempted contact with the guardian of patient #1 on 04/17/21 using the number on the informed consent form. She confirmed she does not seek alternative contact numbers, but only uses the one given to her.

On 6/09/21 at 10:00 a.m., an interview with S1RNConsultant confirmed that the nurses should have been able to make contact with one of the 4 people listed in family contacts before 4/18/21, and that there was documented evidence that contacts had been made by other facility staff; she further confirmed it is not the normal process to wait 4 days to obtain consent to administer ordered medications.


Patient #4

Review of the medical record revealed a 13 year old male admitted 6/06/21with depression and suicidal ideations. A list of parent/guardian contacts was dated 06/06/21.

Review of the Initial Nursing Assessment revealed it was completed on 06/07/21 at 5:47 a.m.

Review of the physician orders revealed the following:
06/06/21 - routine admit orders (no medication orders)
06/08/21 7:15a.m. - please obtain medication list from parent and notify for continuation and obtain consent for use.

Review of the medical record revealed no documented evidence as of 06/09/21 at 3:00 p.m. that medication consent was attempted. There was no evidence that a medication consent form had been completed or that any phone contact had been documented.

Review of the Therapy notes revealed the initial contact with family (father) was documented on 06/07/21 at 10:29 a.m. to discuss care (it was noted by the therapist that his current home meds were Quetiapine 300mg; guanfacine 4mg; and Divalproex).

On 06/10/21 at 9:30 a.m., during an interview with S1RNConsultant, the above findings were discussed. A follow-up interview with S1RNConsultant on 06/10/21 at 11:15 a.m. confirmed that no medication consent had been obtained by nursing at this time. She stated that the nurses told her they had contacted the father and he had refused, and stated he would call back later; however, she confirmed that the nurses had no documented evidence of a conversation with the father of patient #4 in which he refused medications and had not completed the consent form documenting which medications they requested consent for and which he had refused.