HospitalInspections.org

Based on interviews and record reviews the hospital failed to ensure 2 of 10 patients' (Patient #11 and Patient #15's) nursing plan of care listed and/or addressed current problems and/or needs in that

1) Patient #11 received Warfarin (Coumadin) blood thinner daily and aspirin daily related to a medical history of CVA (Cerebrovascular Accident).

2) Patient #15 was admitted with asthma, shortness of breath with ordered inhalation medications. Patient #15 further was admitted on Ceftin (antibiotic) for a respiratory infection.

Findings included:

1) Patient #11's physician order/admission medication reconciliation dated 09/22/15 timed at 2105 reflected, "Aspirin Chewable 81 mg (milligrams) po (by mouth) every AM (morning)...continue...indication...Coronary Artery Disease...Warfarin (Coumadin) 1 mg po every Monday, Wednesday, Friday...Warfarin 2 mg po at HS (hour of sleep) every Tuesday, Thursday, Saturday and Sunday..."

The Medication Administration Record dated 09/23/15 through 09/25/15 reflected the following:

Patient #11 was administered Aspirin chewable tablet 81 mg po every morning given at 0900 on 09/23/15, 09/24/15 and 09/25/15.

Patient #11 was administered Warfarin 1 mg po at 1800 on 09/23/15 and at 0900 on 09/25/15.

Patient #11 was administered Warfarin 2 mg po at 09/24/15 at 1800.

Patient #11's Multidisciplinary Integrated Treatment Plan dated 09/23/15 revealed no documented problem, short/long term goals which addressed Patient #11's Cerebrovascular Accident and administration of Warfarin therapy. No monitoring and/or any signs and symptoms such as bruising and lab levels was identified and/or addressed on the treatment plan.

On 10/21/15 at 1530 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #11's medical record which included the treatment plan. Personnel #2 verified the treatment plan did not address Patient #11's Cerebrovascular Accident and the administration of blood thinners.

2) Patient #15's 08/27/15 timed at 2200 Physician Order/Admission Medication Reconciliation reflected, "Ipratropium two puffs 0.02 inhalation every day for asthma...ventolin two puffs 90 micrograms inhalation every four hours as needed for shortness of breath...Advair inhaler 250/50 inhalation every day Asthma...Ceftin 500 mg (milligrams) po (by mouth) BID (twice daily) times ten days..."

The 08/27/15 Medication Administration Record reflected, "Ceftin 300 mg (milligrams) po (by mouth) twice daily times 10 days...administered 08/27/15 at 2100 and on 08/28/15 at 0900 and 2100..."

The 08/27/15 Multi-disciplinary Note timed at 2215 reflected, "Patient complains of shortness of breath...Ventolin...90 micrograms given..."

The 08/28/15 Multi-disciplinary Note timed at 2100 reflected, "Gave patient Ventolin two puffs at patient request due to shortness of breath..."

The 08/31/15(physician) progress note dated 08/31/15 timed at 0650 reflected, "Patient complains of congestion, cough with yellow sputum..."

Patient #15's Multidisciplinary Integrated Treatment Plan dated 09/08/15 revealed no documented problem, short/long term goals which addressed Patient #15's respiratory infection, asthma and shortness of breath and treatment ordered and/or provided.

On 10/23/15 at 1344 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #15's medical record which included the treatment plan. Personnel #2 verified the treatment plan did not address Patient #15's respiratory infection nor address the need for inhalation medications for asthma and shortness of breath.

The Hospital policy and procedure entitled, "Treatment Planning:Integrated/Multidisciplinary" with a revision date of 03/2015 reflected, "The treatment plan will be appropriate to the needs and interests of the patient...toward restoring and maintaining optimal levels of physical...functioning...treatment plan shall contain...any non-psychiatric conditions...a list of problems and needs that are to be addressed during the patients hospitalization."

Based on record review and interview, the hospital failed to administer patient medications in accordance with applicable licensing requirements to obtain informed medication consent for each individual medication for 4 of 8 patients (Patient #1, #2, #14, and #6) in that

1) Patient #1 received the first doses of her psychotropic medications without informed consent. A verbal consent for both medications was obtained 9 hours after initial medication administration and after surveyor inquiry.

2) Patient #2 received 26 doses of her mood stabilizing medication, 32 doses of her antipsychotic medication, and seven doses of her anti-anxiety medication without the patient's or her legal representative designee's informed consent

3) Patient #14 received 14 doses of his antipsychotic medication without informed consent.

4) Patient #6 received four times the originally consented dose of Zyprexa on nine different occasions without evidence that the patient consented to the increase.


Findings included:

1) Patient #1's Admit Orders dated 10/20/15 at 22:00 reflected the patient was admitted for suicidal ideations.

Medication Administration Record dated 10/21/15 at 09:00 reflected Patient #1 received Depakote ER tablets 500 mg (milligram) for "mood" and Celexa 20 mg for depression.

During an interview on 10/21/15 at 16:45 Personnel #10 acknowledged that Patient #1 received her medication without informed consent.

Informed consent for psychotropic medications (Celexa, Depakote) was dated 10/21/15 at 18:00 and noted that verbal consents were obtained at that time.

2) Patient #2's Admit Orders dated 10/05/15 at 12:15 reflected an admission diagnosis of Cyclothymia.

Patient #2's Physician Orders dated 10/05/15 at 15:05 reflected an order for the administration of Depakote ER 500 mg (milligram) at bed time. The document labeled Informed Consent for Psychotropic Medication (Depakote) dated 10/06/15 at 17:00 reflected that Patient #2 was "unable to sign." The signature line for a "patient representative designee if unable to sign" was left blank. Patient #2's Medication Administration Records dated 10/05/15 at 21:00 and 10/21/15 at 15:00 reflected the patient received 26 doses of Depakote without informed consent.

Patient #2's Physician Order/Admission Medication Reconciliation dated 10/05/15 reflected an order to administer Seroquel 25 mg in the morning and Seroquel 50 mg at bed time for the diagnosis of Psychosis. The document labeled Informed Consent for Psychotropic Medication (Seroquel) dated 10/06/15 at 17:00 reflected that Patient #2 was "unable to sign." The signature line for a "patient representative designee if unable to sign" was left blank. Patient #2's Medication Administration Records dated 10/05/15 at 21:00 through 10/21/15 at 09:00 reflected that 32 doses of the antipsychotic medications had been administered without informed consent.

Physician Orders dated 10/18/15, time not legible, noted an order for Buspar 5 mg to be administered three time daily by mouth. The document labeled Informed Consent for Psychotropic Medication (Buspar) dated 10/19/15 reflected that Patient #2 was "unable to sign." The signature line for a "patient representative designee if unable to sign" was left blank. Patient #2 received seven doses of Buspar 5 mg (on 10/19/15 at 09:00, 15:00, 21:00, on 10/20/15 at 09:00, 15:00 and 21:00, and on 10/21/15 at 09:00) without informed consent.

Personnel #9 was observed placing a spoonful of yellow substance into Patient #2's mouth on 10/21/15 at 09:45. The surveyor asked Personnel #9 what was placed into Patient #2's mouth. Personnel #9 responded, "I have to verify with the MAR [Medication Administration Record] because she [Patient #2] gets several [medications]."

During an interview on 10/21/15 at 09:55 Personnel #9 stated he administered Buspar and Depakote to Patient #2 who was "confused." On 10/21/15 at 15:50 Personnel #9 acknowledged that there were no informed consents for the Buspar and Depakote medications that he had administered earlier.

During an interview on 10/21/15 at 15:30, Personnel #2 acknowledged that Patient #2 received those psychotropic medications without informed consent.

3) Patient #14's Physician Discharge Summary dated 10/08/15 at 15:09 reflected the patient's diagnoses included Schizophrenia, Dementia, and Cognitive Decline. Patient #14 was admitted on 09/24/15 and discharged on 10/08/15.

Patient #14's Medication Administration Record dated 09/25/15 at 09:00 through 10/08/15 at 18:00 reflected the patient received one dose of Prolixin for psychosis, nine doses of Zyprexa and four doses of Seroquel for Schizophrenia. There was no evidence that informed consents had been obtained.

4) Patient #6 signed the document labeled Informed Consent for Psychotropic Medications for Zyprexa 5 mg on 08/02/15 at 00:45. The medication was to be administered daily at 18:00.

Patient #6's Physician Progress Notes dated 08/07/15 reflected Zyprexa was increased to 10 mg to be administered twice daily at 09:00 and 18:00.

Medication Administration Record dated 08/08/15 through 08/11/15 reflected Zyprexa 10 mg was administered twice daily and once on 08/12/15 at 09:00.

During an interview on 10/22/15 at 15:00 Personnel #2 acknowledged the above findings.


Review of Hospital Policy TX-Med-16 Medication Education Documentation/Informed Consent dated 09/2013 reflected the purpose "to allow the patient to be an active participant in their treatment...provide the patient with education that will decrease their fears and increase...treatment compliance..."

Based on interviews and record reviews the hospital failed to ensure 1 of 10 patients (Patient #15's) physician discharge summary included and/or addressed a recapitulation of current problems and/or needs in that

1) Patient #15 was admitted with asthma, shortness of breath with ordered inhalation medications. Patient #15 further was admitted on Ceftin (antibiotic) for a respiratory infection.

Findings included:

1) Patient #15's 08/27/15 timed at 2200 Physician Order/Admission Medication Reconciliation reflected, "Ipratropium two puffs 0.02 inhalation every day for asthma...ventolin two puffs 90 micrograms inhalation every four hours as needed for shortness of breath...Advair inhaler 250/50 inhalation every day Asthma...Ceftin 500 mg (milligrams) po (by mouth) BID (twice daily) times ten days..."

The 08/27/15 Medication Administration Record reflected, "Ceftin 300 mg (milligrams) po (by mouth) twice daily times 10 days...administered 08/27/15 at 2100 and on 08/28/15 at 0900 and 2100..."

The 08/27/15 Multi-disciplinary Note timed at 2215 reflected, "Patient complains of shortness of breath...Ventolin...90 micrograms given..."

The 08/28/15 Multi-disciplinary Note timed at 2100 reflected, "Gave patient Ventolin two puffs at patient request due to shortness of breath..."

The 08/31/15(physician) progress note dated 08/31/15 timed at 0650 reflected, "Patient complains of congestion, cough with yellow sputum..."

The Physician Discharge Summary with a dictation date of 10/20/15 reflected, "Medical status monitored through treatment course...hospital course...admitted to inpatient program...placed on Celexa and Valium...no further thoughts of harm...discharged 09/08/15...discharge medications Prozac...follow-up with assisted living...continuation of psychiatric medication management reinforced..." No documentation was found in the discharge summary which addressed Patient #15's asthma, respiratory infection and continued use of inhalation medications.

On 10/23/15 at 1344 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #15's medical record which included the treatment plan. Personnel #2 verified the physician discharge summary did not address Patient #15's respiratory infection nor address the need for inhalation medications for asthma and shortness of breath.