HospitalInspections.org

Based on documentation review and interview, the hospital failed to ensure that an informed consent for all Psychoactive Medications was signed by the patient, the legally authorized representative, or had a court order signed by the County Judge to administer Psychoactive medications as in 1 (Patient #1) of 3 (Patient #1, #2, and #3) patient medical records reviewed.


Findings:

Patient #1
A review of Patient #1's medical record was conducted on 12/01/2025 after 11:30 AM.

Patient #1 was voluntarily admitted to the hospital on August 13, 2025, with an admitting diagnosis of Major Depressive Disorder, recurrent, without psychotic features, Cannabis Use Disorder, and Alcohol Use Disorder.

A medication order was written by Physician #5 on 8/14/2025 for Latuda (antipsychotic medication) for mood. A review of the medication administration record (MAR) confirmed Patient #1 was administered Latuda on 8/14/2025 at 5:00 PM by the nurse. Patient #1 refused the medication on 8/15/2025 and 8/16/2025. Further review of the medical record revealed Patient #1 had not signed an informed consent for the administration of Latuda until 8/17/2025 at 5:00 PM.

An interview was conducted with Registered Nurse (RN) Staff #1 and Assistant Chief Nursing Officer (ACNO) Staff #3 on 12/15/2025 at 1:00 PM. Both RN's confirmed Patient #1 was administered the medication before an informed consent was signed.

A review of the hospital policy titled "Psychoactive Medication Consent", Policy # MM.3.09, with a reviewed date of 5/30/2025, was as follows:

"PURPOSE
To assure all patient rights are respected regarding their treatment with psychoactive medications.
POLICY
Except in an emergency, all patients at Dallas Behavioral Health Hospital will be informed of their rights and give informed consent PRIOR to administration of psychoactive medication ..."

RN Staff #1 and ACNO Staff #2 confirmed Patient #1 was administered Latuda 40 milligrams by mouth before she signed an informed consent.