HospitalInspections.org

Based on a review of documentation and the clinical record, the governing body failed to appoint a chief executive officer responsible for managing the facility. Failure to properly manage the facility can compromise patient safety.

Findings were:

During a review of the clinical record for patient #1, the following was noted:

The patient received the following medications during his stay:

· Amitryptilline 10 po/given at 8:00 am on 4-17, 4-18 and 4-19-15
· Tenex 1 mg po bid (dosed per facility therapeutic interchange)/given at 8:00 pm on 4-16-15
· Tenex 2 mg po q am (dosed per facility therapeutic interchange)/given at 8:00 am on 4-17-15
· Concerta 27 mg po q am/given at 8:00 am on 4-18 and 4-19-15
· Risperdal 0.25 mg po bid/given at 8:00 am and 8:00 pm on 4-18, given at 8:00 am on 4-19-15

A nursing note written on 4-17-15 at 8:00 pm stated "Mom voices need to talk to Dr. [Drs name] - Will pass on report ...Mom states doesn't want any ADHD meds or Amitriptyline given to son - med nurse informed."

Facility policy #1000.34 titled "Informed Consent for treatment with Psychoactive Medication" states the following:
"Refusal to consent or receive psychoactive medication: actions which include the following behaviors:
· The patient or LAR communicates orally, in writing or through sign language that he/she refuses the psychoactive medication."

The above was confirmed in an interview with the Chief Executive Officer, Interim DON and Director of PI/Risk Management on the evening of 6-11-15.