HospitalInspections.org

Based on record review and interview the facility staff failed to document informed consent for medication changes in 1 (Patient #1) of 10 medical records reviewed.

Findings include:

A review Patient #1's History and Physical on 1/21/2021 at 8:57 AM revealed "MMSE (mini mental state exam-a brief structured test of mental status): 1. Intellectual disability 2. Unspecified mood disorder. Treatment Plan/Recommendations: 1. Admit for safety assessment and stabilization of symptoms. 5. Discontinue Bupropion (antidepressant) 6. Sertraline (antidepressant) 50 mg p.o. (per mouth) daily 7. Change Depakote (used to treat seizure disorders and certain psychiatric conditions) to Depakote ER (extended release) 1000 mg p.o. daily."

The facility policy, titled "Informed Consent for Medication", dated 5/2019, revealed: "Procedure: 1. In addition to the physician's explanation, written and verbal medication information will be given to each patient and/or guardian receiving prescribed medications for the first time."

There was no evidence Patient #1's medical record that Informed consent for Sertraline was obtained from Patient #1 or his guardian prior to the above medication changes.

During an interview on 6/9/2021 at 9:45 AM with Nurse Manager B stated "I did not find a signed consent form for Sertraline in Patient #1's chart."