HospitalInspections.org

Based on interview and record review the facility failed to obtain informed consent from the patient for the administration of psychotropic medications for one (P-5) of 5 patients reviewed for informed consent, resulting in the loss of a patient's right to make an informed decision. Findings include:

On 8/5/25 at 1000, review of the medical record revealed P-5 was a male 23-year-old male, admitted to the facility on 7/22/25 at 1455. P-5 was admitted with the primary diagnosis of bipolar disorder, with current episodes of manic behaviors.

Record review revealed that P-5 was his own legal guardian. The social work notes of 7/25/25 at 1124, revealed that father had legal medical power of attorney and had submitted a petition for emergency guardianship to the county court, with a hearing scheduled for 8/13/25. No emergency guardianship documents were found in the record.

On 7/31/25 at 1408, a medication consent for Risperdal, lithium carbonate, and Uzedy LAI (long acting injectable), all psychotropic drugs, was signed by the mother who was listed as "emergency guardian". Staff double witnessed mothers' signature on medication consent form.

On 8/5/25 at 1100, an interview with the director of clinical services Staff O revealed that patient's parents were the medical power of attorney, and that they were in the process for filing for emergency guardianship. On 8/6/25 at approximately 1100. Staff O provided a verbal update stating she checked with the court and emergency guardianship was not in place or obtained during P-5's stay.

Review of policy titled, "Obtaining Consent for Psychotropic Medications Recipient Rights", dated 5/23, revealed: "It is the policy of (facility)...that all medication will be administered in accordance with the patient's rights to informed consent ...Initial administration of psychotropic ...Informed consent from the patient or ...guardian is necessary to administer psychotropic medications"