HospitalInspections.org

Based on a review of the clinical record, facility documentation and an interview with staff, the facility failed to protect and uphold the patient's right to make informed decisions regarding his or her care, as the facility failed to obtain informed consent for each psychoactive medication prior to administration (per facility policy).

Findings were:

Review of the clinical record for patient #2 revealed that patient #2 received the following psychoactive medications during his stay:
* Clonidine
* Aricept
* Haldol
* Remeron
Psychoactive medication consent forms had been signed by the patient #2's wife, although there was no medical power of attorney on file and the patient's wife had no legal right to provide consent.

Facility policy MM-02 titled "Psychoactive Medication Administration/Consent - Texas" states, in part:
"Policy:
Medications are administered to patients by qualified licensed personnel in compliance with regulatory bodies after verbal informed consent has been provided by the patient...If psychoactive medications are prescribed by a Physician or NPP, a writen informed consent must be obtained from the patient or legally authorized representative."

In an interview with staff #4 on 9-1-21, staff #4 confirmed that there was no medical power of attorney on file and that the wife had no legal right or power to provide consent.