HospitalInspections.org

Based on record review and interview, the facility failed to ensure all records contained properly executed informed consent forms for treatments specified by the medical staff for four of ten medical records reviewed (Patient #1, #2, #7 and #9). This could affect all patients receiving services from the facility. The patient census was 22.

Findings include:

1. Review of the medical record for Patient #1 revealed he/she was admitted to the hospital on 10/19/2020 and discharged on 10/30/2020. The patient was admitted with diagnoses including schizoaffective disorder, bipolar, homicidal ideations, mild intellectual disabilities, auditory hallucinations, explosive disorder and borderline personality. The medical record revealed the informed consent for psychotropic medication did not list the medications on the form and was not signed by the nurse or patient/guardian.

2. Review of the medical record for Patient #2 revealed he/she was admitted to the hospital on 11/25/2020 and discharged on 12/04/2020. The patient was admitted with diagnoses including suicidal ideation, and detox. Review of the informed consent for psychotropic medication listed the medications, was signed by the nurse, but did not have the patient's signature on it.

3. Review of the medical record for Patient #7 revealed he/she was admitted to the hospital on 03/27/21 with diagnoses including schizoaffective disorder, bipolar and alcoholism. The informed consent for psychotropic medications listed the medications and was signed by the patient, but was not signed by the nurse.

4. Review of the medical record for Patient #9 revealed he/she was admitted to the hospital on 03/27/21 with diagnoses including depression, anxiety and substance abuse. The informed consent for psychotropic medications listed the medications and was signed by the patient, but was not signed by the nurse.

The findings were confirmed with Staff I and Staff A prior to the exit conference on 04/01/21.