HospitalInspections.org

Based on interview and record review the facility failed to ensure a patient's right to make decisions about their care when a consent for the administration of a psychotropic medication, for (1) one of (4) four patients, was not obtained prior to the administration of Ativan for anxiety. (Patient #1)

Findings include:

Review of the facility provided policy Psychoactive Medication Administration/Consent (dated 2/01/2017) reflected, " ...To provide a process for ensuring patients and/or families are involved in decisions about care, treatment and services .... Definitions: ...Psychoactive medications- Medication whose primary intended therapeutic effect is to treat or ameliorate the signs or symptoms of mental disorder, or to modify mood, affect, perception, or behavior ... 2. The initiation of new psychoactive medications during admission requires a signed informed consent form ....4. The patient must be informed of: The name of the medication ..., The probable health and central health consequences to the patient ... the existence of generally accepted alternative forms of treatment ... the fact that side effects of varying degrees of severity are a risk of all medication ... Instruction that the patient may withdraw consent at any time ..."

Review of Patient #1's Medication Administration records dated 8/2/18 at 2:00 pm reflected Ativan 1 mg (miligram) po (by mouth) bid (twice a day) was ordered. The patient did not sign a consent for the Administration of the Ativan.

Review of the medical records on 8/4/18 revealed at 9:00 pm Ativan 1 mg was administered, for anxiety.
On 8/7/8 at 8:12 am and at 3:51 pm Ativan 0.5 mg was administered, for anxiety.

During an interview on the afternoon of 4/23/19, in the administrative conference room, Staff #1, Risk Manager confirmed the finding.