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Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 4) had a completed list of medications listed on the Psychiatric Medications Advisement form and documentation of Patient 4's refusal to sign the Psychiatric Medication Advisement form. This failure posed the increased risk for the patient to have lack of knowledge and understanding of the risk and benefits of the medications.

Findings:

Review of the hospital's P&P titled Medication Advisement for Involuntary Patients dated August 2024 showed in part:

* Policy: Psychiatric patients must be given oral and written information about the proposed course of treatment with a psychotropic medication before the medication is administered, except in emergency situations. If different and/or additional psychotropic medication is proposed, the patients must be given oral and written information about this medication before it is administered, except in emergency situations.

Documented advisement about the proposed course of the treatment is required for the following categories of medications:

- Neuroleptics (antipsychotics)
- Antidepressants
- Mood stabilizer
- Antiparkinson medications
- Anticonvulsant
- Minor tranquilizer

The oral advisement shall be performed by the patient's physician and shall consist of a full explanation of the treatment with each proposed psychotropic medication, including:

- The nature of patient's mental condition.

- The reason for taking the medication, including the likelihood of the patient's improving or not improving without the medication.

- A statement that the patient may withdraw his/her consent at any time. The patient should be advised that he or she may withdraw the consent by stating such intention to any member of the treating staff.

- The reasonable alternative treatments available, if any.

- The name and type of medication, range of frequency of administration, range of dosage amount including the use of PRN orders, method of medication administration, and duration of taking the medications.

- The probable side effects of the medication that are known to commonly occur and any particular side effects likely to occur to the particular patient. The possible additional side effects that may occur in patents taking the medication longer than three months. If applicable, the patient must be advised that such side effects may include persistent involuntary movement the face or mouth and might also include similar movement of the hands and feet, and that these symptoms of tardive dyskinesia are potentially irreversible and may appear after the medication has been discontinued.

- The right to refuse medication.

If the patient agrees with the administration of the proposed psychotropic medication, he/she should sign the Psychiatric Medication Advisement form (M11141) indicating that he/she has received the required information about the proposed treatment with the particular psychotropic medication and has consented to the medication.

The patient may later withdraw consent and refuse the administration of psychotropic medication, in which case no medication may be administered unless an emergency exists, or an order of incapacity is issued by the judge.

Psychotropic medications may be administered to an involuntary patient if the patient is given the above-referenced medication-advisement information, and does not refuse the medication, even if the patient does not expressly agree to sign the medication advisement form. The physician providing the medication-advisement information should document the patient's refusal to sign the medication advisement form, which should be placed in the medical record. A copy of the medication advisement form should be given to the patient.

* Procedure:

- The physician is responsible for discussing with and offering written materials to the patient about the proposed course of treatment with psychotropic medication(s). This should be documented in the medical record.

- The physician shall document on the Psychiatric Medications Advisement form the specific name of the proposed psychotropic medication(s) in the fields provided on the form.

- The physician shall obtain the signature of the patient or his/her conservator, if any consenting to the medication, and then shall sign, date, and time the Psychiatric Medication Advisement form.

- If the patient does not refuse the medication but does not wish to sign the Psychiatric Medication Advisement form, the physician shall: documentation on the form that the patient declined to sign the form; and sign, date, and time the form.

- The completed Psychiatric Medication Advisement form shall be placed in the patient's medical record.

- A copy of the Psychiatric Medication Advisement form shall be given to the patient.

- The fact that the information has or has not been given shall be indicated in the patient's medical record. If the information has not been given, the designation person shall document in the patient's medical record the justification for not providing the information.

On 3/5/25 at 0956 hours, interview and concurrent review of Patient 4's closed medical record was conducted with the Assistant Hospital Administrator, Psychiatry Chair, Health Facility Consult, Mental Health SW II, Psych SW 1, and Psych SW 2.

Patient 4's closed medical record showed Patient 4 was admitted to the Psych ED on 1/16/25, on a 5150 hold. The patient was admitted to the Psych unit on 1/20/25, and discharged on 2/14/25.

On 3/5/25 at 1014 hours, interview with the Psychiatric Chair about Patient 4's psychotropic medication regimen. The Psychiatric Chair stated the patient received Risperdal (antipsychotic) for poor emotional regulation common problem with intellectual disability. The Psychiatric Chair added Risperdal was changed to injectable medication Invega Sustenna (extended-release antipsychotic medication).

Review of the Discharged Summary dated 2/14/25, showed "stopped Risperdal 2 mg/2 mg (2/4-2/12), given conversion to LAI (long-acting injection) ...s/p Invega Sustenna 234 mg IM on 2/10, Invega Sustenna 156 mg IM ordered for 2/13."

Review of Patient 4's Psychiatric Medication Advisement showed the physician signed on 1/16/25 at 1836 hours, for the following medication of risperidone (as same as Risperdal), Haldol (antipsychotic medication), olanzapine (antipsychotic medication), lorazepam (an antianxiety medication), and Benadryl (an antihistamine).

Review of Patient 4's EMAR showed the following:

* The order for Thorazine (antipsychotic medication) 50 mg po every morning and HS. Patient 4 received Thorazine 50 mg on the following dates:

- 1/18/25 at 1100 and 2118 hours.
- 1/19/25 at 1042 hours.
- 1/2025 at 0908 hours.

* On 1/21/25 at 1118 hours, Thorazine 75 mg po every morning and evening. Patient 4 received Thorazine 75 mg po on the following dates:

- 1/2125 at 2145 hours.
- 1/22/25 at 1009 and 2048 hours.
- 1/23/25 at 0946 and 2047 hours

The Health Facility Consult was asked about the psychiatric medications listed on the Psychiatric Medications Advisement Form and the documentation of the physician for the patient's refusal to sign. The Health Facility Consult could not show the complete list of the psychotropic medications and physician's documentation that Patient 4 refused to sign the Psychiatric Medications Advisement Form.

Based on interview and record review, the hospital failed to ensure two LVNs performed patient care under the RN supervising as per the hospital's nursing policy for three of four sampled patients (Patients 1, 2, and 3). This failure created the increased risk to the safety of patients.

Findings:

Review of the hospital's Nursing Policy Manual-Assignment of Patient Care revised 9/18/18, showed the care of each patient is under the supervision and direction of a Registered Nurse. The assigned staff member will provide director and indirect patient care activities/tasks as delegated within their scope of practice.

Review of the Class Specification Bulletin for Licensed Vocational Nurse I revision 4/25/73, showed LVN I 's normally work under the supervision of a registered nurse or physician and administer care for the patient ordered by the physician or contained in a nursing care plan.

Review of the hospital's P&P titled Assessment, Reassessment, and Data Collection dated 1/18/24, showed the following:

- Physical assessment is defined as this portion includes a head-to-toe body system evaluation involving systematic and continuous collection, analysis, and communication of data following the nursing process; utilize critical thinking to interpret the data collected in developing, guiding, and prioritizing a patient-centered individualized plan of care.

- Documentation: all aspects of patient care shall be documented in the EHR in accordance to the nursing process following the specified time within the care setting, and/or unit reassessment frequency parameters.

Review of the Table 1 - Reassessment Frequency Parameters of the Nursing Policy No. 030 -Assessment, Reassessment, and Data Collection showed these assessments shall be done at a minimum as described for a 12-hour shift. The parameters for med/surg unit include neurological, cardiovascular, neurovascular, respiratory, GI/GU, integumentary, IV site with continuous infusion, dressing and wounds, level of activity, and response to pain management.

On 3/5/25 at 0942 hours, Patients 1, 2 and 3's closed medical records were reviewed the Director Nursing Quality Admin, 4 East Nursing Manager, and Accreditation & Reg. Compliance, Coordinator.

1. Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 12/20/24 to the Med/Surg unit. The medical record showed on 1/23/25 at 0810 hours, LVN 1 documented the Adult Systems Assessment, the assessment of the patient's baseline/initial assessment for the following: neurological, respiratory, cardiovascular, edema assessment, gastrointestinal, genitourinary, integumentary, incision/wound/skin abnormality. LVN 1 signed on the perform and verify section without a RN review.

2. Patient 2's closed medical record showed Patient 2 was admitted to the hospital on 1/15/25. The medical record review showed LVN 1 documented on 1/23/25 at 0919 hours, the patient's assessment including neurological, respiratory, breathing sounds assessment, cardiovascular, edema assessment, gastrointestinal, genitourinary, integumentary, and incision/wound/skin abnormality. LVN 1 documented the Perform and Verify completed on 1/23/25 at 0919 hours. The area for Reviewed by RN was blank.

3. Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 2/13/25. The medical record review showed LVN 2 documented on 3/3/25 at 0842 hours, the LVN assessed the patient's Adult Systems Assessment including neurological, respiratory, cardiovascular, pulses, neurovascular, edema assessment, gastrointestinal, genitourinary, musculoskeletal assessment, integumentary, and incision/wound/skin abnormality. LVN 2 documented the Perform and Verify completed on 3/3/25 at 0842 hours. The area for Reviewed by RN was blank.

The Director Nursing Quality Admin confirmed the findings.