HospitalInspections.org

Based on interview and record review the facility failed to provide 5 of 10 patients, Patients #1, #2, #5, #6 and #8 the right to make informed decisions regarding his or her care when they failed to provide the patients with informed consent before taking neuroleptic medications. Findings include:

A review of the facility nursing policy for neuroleptic medication titled Mercy Mental Health Policy: Medications: Voluntary and Emergency Administration of Neuroleptic and dated 10/20/2008 revealed that "All patients will be educated on the benefits and risks of neuroleptic medications regardless of voluntary, involuntary or commitment status. Neuroleptic medications require written informed consent and may be prescribed for patients with psychiatric conditions who exhibit emergent symptoms."

A review of the medical record for Patient #1 revealed that she was admitted to the facility on 10/3/2011 with diagnoses that included Bipolar Affective disorder. Patient #1's Medication Administration Record revealed that her medications included Seroquel,a neuroleptic medication. (Neuroleptic medications have the ability to cause severe or life threatening side effects.) A review of the medical record revealed no informed consent for the use of the neuroleptic medication.

A review of the medical record for Patient #6 revealed that she was admitted to the facility on 10/20/2011 with diagnoses that included Psychosis. Patient #6's Medication Administration Record revealed that her medications included Abilify,a neuroleptic medication. A review of the medical record revealed no informed consent for the use of the neuroleptic medication.

A review of the medical record for Patient #2 revealed that she was admitted to the facility on 10/19/2011 with diagnoses that included Depression. Patient #2's Medication Administration Record revealed that her medications included Abilify, a neuroleptic medication. Although a review of the medical record revealed a physician statement indicating a discussion with the patient regarding medication risks and benefits, no written informed consent for the use of the neuroleptic medication was found.

A review of the medical record for Patient #5 revealed that she was admitted to the facility on 10/1/2011 with diagnoses that included Fetal Alcohol Syndrome. Patient #5's Medication Administration Record revealed that her medications included Thorazine and Haldol, neuroleptic medications. Although a review of the medical record revealed a physician statement indicating a discussion with the patient regarding medication risks and benefits, no written informed consent for the use of the neuroleptic medication was found.

A review of the medical record for Patient #8 revealed that she was admitted to the facility on 9/3/2011 with diagnoses that included Psychosis. Patient #8's Medication Administration Record revealed that her medications included Zyprexa, a neuroleptic medication. Although a review of the medical record revealed a physician statement indicating a discussion with the patient regarding medication risks and benefits, no written informed consent for the use of the neuroleptic medication was found.

Employee C/RN/Interim Patient Care Supervisor was interviewed on 10/24/2011 at 1:45 p.m. and she confirmed that the written informed consents were not on the patient charts for Patients #1, #2, #5, #6 and #8.