HospitalInspections.org

Based on record review and interview, the hospital staff failed to follow their policies and procedures for education of psychotropic medications and obtaining informed consent prior to administration of psychotropic medications for 1 of 10 patients receiving psychotropic medications (Patient #1) in a total of 10 medical records reviewed.

Finding include:

Record review of the "Client Rights an the Grievance Procedure for Inpatient and Residential Services for Client Receiving Services in Wisconsin for Mental Illness, Alcohol or Other Drug Abuse, or Developmental Disabilities" dated 8/2010 under Treatment and Related Rights..."You must be informed of your treatment and care, including alternatives to and possible side effects of treatment, including medications...No treatment or medication may be given to you without your written, informed consent, unless it is needed in an emergency to prevent serious physical harm to you or others..."

Record review of Patient #1's medical record revealed Patient #1 was admitted 4/7/2021 with depression and psychosis and discharged 4/14/2021. The Medication Administration Record revealed the first dose of psychotropic medication Olanzapine was administered on 4/7/2021 at 6:13 PM, Buspirone administered 4/8/2021 at 8:37 AM, Sertraline administered 10/8 at 8:42 AM, Quetiapine administered 4/8/2021 at 7:44 PM and Clonazepam administered 4/9/2021 at 7:53 PM. The medical record did not reveal any medication consent forms or documented education prior to administration of the first doses.

On 10/25/2021 at 12:10 PM in interview with 6W Manager E, Manager E stated that every patient needs to sign the Medication Consent form prior to receiving the first dose of a psychotropic medication. 6W Manager E confirmed that the consents were not in the medical record for Pt. #1.