HospitalInspections.org

Based on document review, medical record review and interview, the hospital staff failed to ensure the patient or patient representative was afforded the right to refuse medications as a part of their plan of treatment for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the family information packet "Rights and Responsibilities" revealed, " ...Patient Rights ...The patient has the right to make decisions regarding the health care that is recommended by his or her health provider, to include the right to give informed consent. Accordingly, the patient may accept or refuse any recommended treatment ..."

2. Medical record review revealed Patient #1 was a 13 year old female who was admitted to the adolescent psychiatric unit on 5/29/18 for suicidal ideations, depression and impulsive behaviors. The patient's representative/guardian signed that she had received a copy of the hospital's Rights and Responsibilities on 5/29/18.

Review of a physician order dated 5/30/18 at 12:30 PM, revealed Prozac 20 milligrams (mg) once daily. Review of the initial psychiatric evaluation performed by Physician #1 on 6/1/18 revealed, "Plan ...Medications start Prozac for dep [depression] & [and] anx [anxiety] ..."

Review of a social services case management note dated 5/30/18 at 4:35 PM revealed, " ...Grandmother [guardian] asked if she could speak with a doctor before patient starts medications. CM [Case Manager] stated she will see if [name of Physician #2] will do a face to face visit with guardians..."

Review of the "Medication First Dose Education & Consent Form" for Patient #1 dated 5/30/18 at 2:45 PM, revealed the grandmother did not give consent for the Prozac medication to be administered. The form was completed by Nurse #1 and witnessed by Nurse #2.

On 5/30/18 at 2:45 PM, Nurse #2 documented a shift note. "Spoke with [name of guardian] to obtain consent for Prozac 20 mg daily. [name of guardian] stated that she prefers for pt [patient] to participate in one- on- one counseling/ therapy sessions, as opposed to medications."

Review of the Medication Administration Record dated 6/3/18 revealed Patient #1 was given one (1) Prozac 20 mg.

3. In an interview in the hospital conference room on 7/17/18 at 1:52 PM, the Unit Manager verified Patient #1 was given one dose of Prozac 20 mg on 6/3/18. She stated Nurse #1 had completed the Medication First Dose Education & Consent Form incorrectly and it was unclear whether the guardian had given consent for the medication.

The hospital failed to ensure the patient representatives request for no medications was honored as part of Patient #1's rights.