HospitalInspections.org

Based on a review of the clinical record, facility documentation and an interview with staff, the facility failed to ensure the patient's right to participate in the development and implementation of his care plan.

Findings were:

Patient #1 was admitted to the facility on 5-1-20. The patient's interdisciplinary treatment plan was formulated on 5-4-20, but contained no signature by the patient to indicate that the patient had been involved in its development. Treatment plan updates were performed on the following dates:
* 5-11-20
* 5-18-20
* 5-25-20
* 6-1-20
* 6-8-20
* 6-15-20
The update performed on 6-1-20 stated that the patient was "aware of plan content" and "unable to sign". No other treatment plan updates contained documentation to indicate that the patient had participated in any way.

Facility policy 7769745 titled "Interdisciplinary Treatment Plan Team Meetings" states, in part:
"Procedures:
1. Basic goals and structure:
...
c. The interdisciplinary treatment team consists of the patient and all clinicians involved in the patients care.
...
4. Master Treatment Plan Review:
a. Within 72 hours of the patient's admission, the master treatment plan is reviewed including a minimum of:
i. The patient
...
c. All members present in the master treatment team review meeting will sign the Master Treatment Plan at the time it is reviewed with the team and the patient. If the patient is unable to sign the document, does not agree to the document or declines to attend the meeting, this will be documented on the master treatment plan."

In an interview with the Director of Nursing on 7-26-22, the Director of Nursing confirmed that 5 of 6 treatment plan updates for patient #1 did not indicate that he had been involved in any way.

Based on a review of documentation and an interview with staff, the facility failed to protect the patient's right to make informed decisions regarding his or her care, as Patient #1 lacked capacity to consent for psychoactive medication, although multiple psychoactive medications were administered without appropriate consent being obtained.

Findings were:

Patient #1 was ordered to receive the following psychotropic medications during his stay: Depakote, Remeron, Seroquel, Trazadone and Zyprexa.

* The Depakote consent indicated the patient was "confused/agitated" with no patient signature or verbal consent indicated. This form was not dated by the patient or the nurses' signatures present. The physician signature indicated a date of "05/30/30" at 1010.
* The Remeron consent indicate the patient was "confused" with no patient signature or verbal consent indicated. This form was not dated by the patient or the nurses' signatures present. The physician signature indicated a date of 05/30/20 at 1010.
* Seroquel indicate the patient was "confused" with no patient signature or verbal consent indicated. This form was not dated by the patient or the nurses' signatures present. The physician signature indicated a date of 05/30/20 at 1000.
* The Zyprexa consent was blank under patient signature, with no verbal consent indicated. This form was not dated by the patient. The nurses' signatures indicated a date of 05/01/20 at 2000. The physician signature indicated a date of 05/03/20 at 1010.

A review of psychiatric progress notes completed throughout the patient's stay noted that he was "confused" and exhibited poor judgment.

Review of the Medication Administration Record (MAR) for patient #1 revealed the following medications were administered:
* Depakote was administered from 05/12/20 through 06/20/20.
* Remeron was administered from 05/02/20 through 05/17/20.
* Seroquel was administered from 05/02/20 through 06/03/20.
* Zyprexa was administered from 05/28/20 through 06/20/20.
* Trazadone was administered from 06/11/20 to 06/20/20. There was no Informed Consent for the Use of Psychotropic Medication(s) form for Trazadone present in this patient's medical record.

The medication administration record for Patient #1 also included the following handwritten order on 06/06/20, "Zyprexa 10 mg PO X 1 Now. Lorazepam 1 mg PO X1 Now. If refuse PO meds give Haldol 5 mg IM X 1 Lorazepam 1 mg X 1 IM". The intramuscular medications of Haldol 5 mg and Ativan 1 mg were administered on 06/06/20 at 1315. Intramuscular injections, also known as "IM back-ups" are ordered when a patient is on court-ordered medication but refuses to take the medication.

Review of the medical record for Patient #1 revealed there was no Court Order present for the administration of psychoactive medication. When the Director of Nursing was asked on 07/25/22 to locate a court order to administer psychoactive medications, she was unable to locate the order.