HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 3 patient (Pts. #3, #4, & #5), the Hospital failed to ensure psychiatric patients have the right to make informed decisions (consent) prior to the administration of psychotropic medication.

Findings include:

1. On 6/16/2021, the Hospital's policy titled, "Informed Consent for Medications," effective August 2020. The policy required, "Informed Consent for the administration of psychotropic medication shall be required for all patients, voluntary or involuntary. Such consent must be written and made a part of the medical record..."

2. On 6/15/2021, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 6/7/2021 with bipolar disorder, (mood swings from depression to manic). Pt. #3's Medication Administration Record (MAR) included that Pt. #3 was administered psychotropic medication but lacked a consent form. The following medication was administered:

-Depakote (treat seizures and bipolar disorder) 250 mg, oral, twice per day on 6/9/21, 6/10/21, 6/11/21, & 6/12/21.

-Zyprexa (treat schizophrenia and bipolar disorder) 5 mg, oral, at bed time on 6/9/21 & 6/10/21.

- Zyprexa, 7.5 mg, oral, at bed time, on 6/11/21, 6/12/21, 6/13/21 & 6/14/21.

3. On 6/15/2021, Pt. #4's clinical record was reviewed. Pt. #4 was admitted on 6/7/2021 with bipolar disorder. Pt. #4's MAR included that Pt. #4 was administered psychotropic medication (Depakote), but lacked a consent form. The following medication was administered:

- Depakote, 250 mg, oral, twice per day, 6/8/21 & 6/9/21.

- Depakote, 500 mg, oral, twice per day, 6/10/21, 6/11/21, 6/12/21, 6/13/21 & 6/14/21

4. On 6/15/2021, Pt. #5's clinical record was reviewed. Pt. #5 was admitted on 6/7/2021 with bipolar disorder. Pt. #5's MAR included that Pt. #5 was administered psychotropic medication (Abilify - treats schizophrenia, bipolar disorder, and depression), but lacked a consent form: The medication was administered on the following days:

- Abilify, 5 mg, oral, once per day, 6/9/21 & 6/10/21.

- Abilify, 10 mg, oral, once per day, 6/11/21, 6/12/21, 6/13/21 & 6/14/21

5. On 6/15/2021 at approximately 12:30 PM, an interview was conducted with the Nurse Risk Manager (E #5). E #5 stated that psychotropic drug consent forms should be completed in the clinical record when patients are being administered psychotropic medication.