HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt. #8) Behavioral Health patients clinical record reviewed for Patient Rights, the Hospital failed to ensure patients were informed about and signed a psychotropic medication consent, prior to psychotropic medication administration.

Findings include:

1. On 01/27/2022 at approximately 11:30 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted on 01/23/2022 at 1:48 PM with diagnosis of Suicidal Ideations. Pt. #8's clinical record included the following.

- Pt. #8's physician's order dated 01/24/2022 at 8:39 PM, included Seroquel (Anti-Psychotic Medication) 100 mg (milligrams) tablet Q HS (daily at bedtime). Pt. #8's MAR (medication administration record) indicated that Pt. #8 received Seroquel 100 mg on 01/25/2022 at 8:50 PM, 01/26/2022 at 8:35 PM and 01/27/2022 at 9:18 PM.

2. On 01/28/2022, the psychotropic consent to medication form signed by Pt. #8 was reviewed. The consent to medication form did not include the dosage range or frequency of administration for Seroquel.

3. On 01/28/2022, Hospital's policy titled, "Psychotropic Medication Education" (Revised 01/2016) was reviewed and required, " ...Informed consent for the use of psychotropic medications shall be obtained from a patient or legally empowered guardian prior to the administration of psychotropic medications ...the patient and/or legal guardian will sign for each medication ordered.

4. On 01/28/2022 at approximately 12:20 PM, the above findings were discussed with E #3 (Manager of Behavioral Health Unit). E #3 stated that the Psychotropic medication consent form should be completed to include the ordered dosage for each psychotropic medication administered. E# 3 stated, "the physician obtain's the psychotropic medication consents, he may have forgot to include the dosage."

Based on document review and interview, it was determined that for 1 of 1 Behavioral Health Representative (E #9) listed on the Behavioral Health Unit schedule reviewed, the Hospital failed to ensure patients received therapeutic psychological education while hospitalized. This has the potential to affect the safety and care of 12 patients on the Behavioral Health unit census.

Findings include:

1. On 01/28/2022, at approximately 10:00 AM, the Behavioral Health Representative schedules were reviewed from 11/01/2021-01/28/2022. The schedules included the following:

-There was no Behavioral Health Representative scheduled on the following dates 12/23/2021 to 12/28/2021 and there was no Behavioral Health Representative coverage on the weekends (saturdays and sundays) from 11/01/2021 to 01/28/2022.

2. On 01/28/2022, at approximately 10:20 AM, the Hospital document titled, "Scope of Services for Inpatient Behavioral Health was reviewed and included, "...Purpose ...Provide acute inpatient treatment in a highly secure and safe environment for patients at risk of harm to self or others due to behavioral health symptoms ...Scope of Services ...Psychoeducational groups ...Group Psychotherapy ..."

3. On 01/28/2022, at 11:45 AM, the job description for the Behavioral Health Representative was reviewed and included, "The Behavioral Representative also works in the areas of patient safety, patient interactions, goal setting, behavioral restructuring and reinforcement ...Duties ...a. Lead groups in educational, solution-driven interventions ...b. document group progression ...d. Coordinates goal setting with patients ..."

4. On 01/28/2022, at approximately 10:30 AM, an interview was conducted with E #3 (Manager of Behavioral Health). E #3 stated, "During the week, psychoeducational therapy is provided three times per day, there is no coverage for the Behavioral Health Representative to conduct group and programming on the weekends. There should be coverage on the weekends, but we don't have anyone else at this time. We are looking to hire another Behavioral Health Representative."

5. On 01/28/2022, at 12:02 PM, an interview was conducted with the Psychiatrist (MD #1). MD #1 stated, "...the more psychotherapeutic education that the patients receive the better. Psychosocial interventions and medication management must work hand in hand."