HospitalInspections.org

Based on record review, interview and policy review, the facility failed to honor a patient's guardian's request to refuse a medication. This affected one (Patient #9) of ten medical records reviewed. The facility's census was 55.

Findings include:

Patient #9 was admitted to the facility on 09/05/24 with a diagnosis of bipolar disorder and discharged on 09/16/24. The Patient #9's Guardian consented to Wellbutrin (a psychotropic medication) to be administered on 09/06/24 at 8:10 PM. On 09/07/24 at 6:05 PM, staff documented Patient #9's guardian declines Wellbutrin. The medical record did not contain evidence of the guardian ever reapproved the administration of Wellbutrin.

Patient #9 received Bupropion (Wellbutrin) 150 milligrams (mg) on 09/07/24 and daily from 09/09/24 through 09/15/24.

The findings were shared with Staff B on 10/01/24 at 12:18 PM and confirmed.

The facility's policy titled "Informed Consent for Psychotropic Medications", dated March 2022, stated to assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights. The Hospital fully supports, endorses and enforces the rights of patients. The Hospital informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements. Patient Rights according to federal guidelines include the following at a minimum: The right to participate in the development and implementation of his or her plan of care and the right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right does not include the provision of treatment or services deemed medically unnecessary or inappropriate.