HospitalInspections.org

Based on interview and record review the facility failed to obtain informed consent for the administration of a psychotropic medication for 1 of 10 patients (#1) resulting in the withholding of information required by the patient's legal representative to make informed decisions regarding care. Findings include:

On 08/15/18 at 1205 Patient #1's (Pt #1) medical record was reviewed. The record indicated Pt #1, a non-verbal 16-year-old male with diagnoses including disruptive mood dysregulation disorder and autistic disorder, was admitted to the Specialized Inpatient Pediatric Unit (SIPU) on 07/10/18 and discharged into the community on 08/08/18. Per the intake assessment dated 07/10/18 at 1709, Pt #1 had a specific family member named as his legal representative. Further review of the record revealed a physician order dated 08/03/18 at 1310 prescribing Prozac 10 milligrams (mg) by mouth every morning for Pt #1. Review of Pt #1's medication administration records revealed Pt #1 was administered a total of five dosages of Prozac (generic name Fluoxetine) 10 mg by mouth every morning from 08/04/18 through 08/08/18, however the medical record contained no evidence that Pt #1's legal representative consented to the administration of Prozac.

During an interview with the Director of Nursing on 08/15/18 at 1315, the Director of Nursing acknowledged, after directly reviewing Pt #1's medical record, there was no evidence that Pt #1's legal representative consented to the administration of Prozac.

During an interview with Psychiatrist K on 08/16/18 at 0945, Psychiatrist K said Pt #1's legal representative was provided with education regarding Pt #1's medication regime, however there was no evidence that Pt #1's legal representative consented to the administration of Prozac. Psychiatrist K indicated the plan was to taper and discontinue Pt #1 from another psychotropic medication and add Prozac to treat certain symptoms. Psychiatrist K said Pt #1 was a minor, nonverbal and unable to provide consent.

On 08/16/18 at 1040 a review of the facility policy and procedure titled, "Medication Consent" last revised November 2011 was completed. This document indicated that it was the policy of the hospital "to obtain written, informed consent from any patient who will be receiving psychotropic medication." This policy also indicated, under procedures section for child and adolescent patients, that it was the intent of the hospital "to obtain informed consent from the responsible parent or legal guardian of a child/adolescent (17 years or younger) patient."