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Based on a review of facility documentation and staff interview, the facility failed to obtain appropriate informed consent for treatment with psychoactive medications in accordance with facility policy for 3 of 3 current inpatients (Patients #9-11).

Findings were:

Facility policy #MM-02 entitled Psychoactive Medication Administration/Consent-Texas, last revised 2/1/17, included the following:
"1. Only licensed prescribers are allowed to provide orders for medications. All medications require an order which is written on the physician/LIP order form and must contain the name, dose, time to be administered, route, and indication ...
3. The prescriber and nurse provide education to the patient and the patient's legally authorized representative in nontechnical language in the patient's primary language. If the information is not provided by the treating physician, the physician must confirm the explanation with the patient and the patient's legally authorized representative within two working days ..."

Patient #10 was prescribed Abilify (an antipsychotic), Vyvanse (a stimulant) and Lexapro (an antidepressant), among other psychoactive medications. She signed consents on dates ranging from 10/11/17 through 10/16/17 to receive these medications. None of the consents were signed by the prescribing physician. Thus there was no documented evidence that the physician had confirmed the information provided the patient about the medications was accurate, or that the patient was aware of medication side effects. The patient had been administered daily doses of these medications.

Patient #9 was prescribed Strattera (a cognition-enhancing medication), trazodone (an antidepressant) and Abilify (an antipsychotic). He signed consents on 10/15/17 and 10/16/17 to receive these medications. None of the consents were signed by the prescribing physician to validate the accuracy of information about the medications or their side effects. The patient had been administered daily doses of these medications.

Patient #11 was prescribed Zyprexa (an antipsychotic) and Geodon (an antipsychotic). He had signed consents on 10/11/17 and 10/13/17 respectively to receive these medications. None of the consents were signed by the prescribing physician to validate the accuracy of information about the medications or their side effects. The patient had been administered daily doses of these medications.

The above findings were confirmed in an interview with the Chief Executive Officer on the afternoon 10/24/17 in the facility conference room.

Based on a review of facility documentation and staff interview, the facility failed to obtain appropriate informed consent for treatment with psychoactive medications in accordance with facility policy and State law for 3 of 3 current inpatients (Patients #9-11).

Findings were:

Facility policy #MM-02 entitled Psychoactive Medication Administration/Consent-Texas, last revised 2/1/17, included the following:
"1. Only licensed prescribers are allowed to provide orders for medications. All medications require an order which is written on the physician/LIP order form and must contain the name, dose, time to be administered, route, and indication ...
3. The prescriber and nurse provide education to the patient and the patient's legally authorized representative in nontechnical language in the patient's primary language. If the information is not provided by the treating physician, the physician must confirm the explanation with the patient and the patient's legally authorized representative within two working days ..."

Patient #10 was prescribed Abilify (an antipsychotic), Vyvanse (a stimulant) and Lexapro (an antidepressant), among other psychoactive medications. She signed consents on dates ranging from 10/11/17 through 10/16/17 to receive these medications. None of the consents were signed by the prescribing physician. Thus there was no documented evidence that the physician had confirmed the information provided the patient about the medications was accurate, or that the patient was aware of medication side effects. The patient had been administered daily doses of these medications.

Patient #9 was prescribed Strattera (a cognition-enhancing medication), trazodone (an antidepressant) and Abilify (an antipsychotic). He signed consents on 10/15/17 and 10/16/17 to receive these medications. None of the consents were signed by the prescribing physician to validate the accuracy of information about the medications or their side effects. The patient had been administered daily doses of these medications.

Patient #11 was prescribed Zyprexa (an antipsychotic) and Geodon (an antipsychotic). He had signed consents on 10/11/17 and 10/13/17 respectively to receive these medications. None of the consents were signed by the prescribing physician to validate the accuracy of information about the medications or their side effects. The patient had been administered daily doses of these medications.

The above findings were confirmed in an interview with the Chief Executive Officer on the afternoon 10/24/17 in the facility conference room.

Based on a review of facility documentation and staff interviews, the facility failed to implement practitioner orders for laboratory studies for 6 of 11 patients (Patients #3 and #7-11).

Findings were:

Facility policy #HIM-01.01 entitled Medical Records, effective date 1/11/16, included the following:
"8. The medical record, via completion of the ...Diagnostic testing results (Lab, Radiology, etc.), provides the following information required to provide patient care, treatment, and services: ...laboratory results."

A review of patient medical records revealed that for Patients #3 and #7-11, laboratory studies had been ordered upon admission. The results of these studies could not be located in the patient records.

In an interview with the facility Chief Executive Officer on the morning of 10/24/17 in the facility conference room, she stated that contract physicians performing patient initial assessments ordered lab studies routinely that hospital psychiatrists did not wish to order. She said the labs were not done, and stated, "So we just need to write an order to discontinue the lab studies ...We thought we'd fixed that."