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HICKORY TRAIL HOSPITAL
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on documentation review and interview, the hospital failed to ensure that all Psychoactive Medication Consents were signed by the patient, the legally authorized representative, or had a court order signed by the County Judge to administer Psychoactive medications in 1 (Patient #4) of 2 (Patient #4 and #5) patient medical record reviewed.
Findings:
Patient #4 was a 22-year-old male admitted to the hospital involuntarily on 5/23/2025 with a diagnosis of Bipolar Disorder-mixed type severe with psychosis, Attention Deficit Disorder, and Autism Spectrum Disorder.
A review of the Medication Administration Record (MAR) for 5/23/2025 and 5/24/2025 revealed Patient #4 was administered the following medications without informed consent from the patient, a legally authorized representative, or a court order signed by the judge.
On 5/23/2025 and 5/24/2025, Patient #4 was administered the following medications:
" ...Risperdal (antipsychotic medication) 1 milligram (mg) on 5/23/2025 at 9:22 PM, and on 5/24/2025 at 8:59 AM.
Lamictal (anti-convulsant medication used as a mood stabilizer), 100 mg on 5/23/2025 at 9:20 PM, and on 5/24/2025 at 8"59 AM.
Thorazine (antipsychotic medication) 50 mg on 5/23/2025 at 9:21 PM, and on 5/24/2025 at 9:00 AM ..."
A review of the hospital policy titled, "Patient Medication Consent", Policy # PH100.37, with an effective date of 5/2023, was as follows:
"I. POLICY:
To inform our patients of the medications that are prescribed.
II. PROCEDURE:
No psychoactive medication may be administered to a patient until the following information has been made available by a physician, licensed nurse, physician assistant, or registered pharmacist and the patient has given written, voluntary consent ..."
A telephone interview was conducted with Staff #2 and Staff #11 on 7/14/2025 at 3:35 PM. Staff #2 confirmed that psychotropic medications were administered to Patient #4 without a legally authorized informed consent from the patient, the patient's legally authorized representative, or a signed court order from the county judge.