HospitalInspections.org

Based on record review and interview, the facility failed to ensure patient rights for each patient, in that,

2 of 20 behavioral patients (Patient #1 and Patient #15) did not have psychotropic medication consent forms for the administered psychotropic medications.

Findings

~ Patient #1 did not have psychotropic medication consent form for the administered psychotropic medications.

The patient transferred on 11/09/2022 at 8:35 AM from Parkland after her evaluation in their ER. Orders were received 11/08/2022 for her admit. She was involuntary and Parkland completed the paperwork with the Dallas County Probate Court prior to her arrival. The chief complaint was psychosis with a past medical history: schizoaffective disorder...Severe Bipolar Disorder, recurrent manic episodes, with psychotic behavior.

Date Administered Medications
11/10/2022 Haldol/Ativan/Benadryl
11/11/2022 Haldol/Ativan/Benadryl
11/12/2022 Haldol/Ativan/Benadryl
11/14/2022 Haldol/Ativan/Benadryl
11/16/2022 Haldol/Ativan

Although the patient allowed the medication at the time, there was no consent form for Haldol, or Ativan. There was no consent form for Benadryl until 11/15/2022.


~ Patient #15 did not have psychotropic medication consent form for the administered psychotropic medication.

The patient was admitted with a chief complaint of intentional drug overdose, suicide ideation, and suicide attempt. Extremely aggressive despite medications and a past medical history of depression.

Date Administered Medication
4/25/2024 Haldol

Although the patient allowed the medication at the time, there was no consent form for Haldol completed.

During record review and interview on 5/16/2024 ending at 12:13 PM, Personnel #3 navigated the records and confirmed Patient #1 and #15 received the non-emergent psychotropic medications without a completed consent form.

The December 2023 reviewed/revised "Informed Consent for Treatment with Psychoactive Medication" Policy required, "The patient must provide informed consent for all non-emergent psychotropic medicines that have been ordered, prior to the patient receiving the first dose.

The February 2017 "Consent to Treatment With Psychoactive Medication Information Sheet for Patients" Handout required, "You have the right to decide whether to take this medication as recommended by your doctor. You can agree to take the medicine, this agreement is called consent...your objection will be recorded..."