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Based on a review of patient medical records, policy and procedures, and staff interviews it was determined that the facility failed to provide care for patients in a safe setting for Patient #1. Patient #1 received medications without a signed MD's order.

Findings:

A review of Patient #1's medical record revealed that Patient #1 was admitted to the facility on 8/19/18 at 7:20 p.m. with a diagnosis of recurrent Major Depressive Disorder (MDD) without psychotic features. Patient #1 was assigned to the care of MD #1. MD #1 performed an admission psychiatric evaluation on Patient #1 on 8/20/18 at 1:50 p.m.

A review of admitting orders dated 8/19/18 at 8:15 p.m. signed by the nurse practitioner (NP #2) for MD #1 revealed that the following medications: - Abilify (a mood stabilizing medication) 5 mg PO (by mouth) twice a day, Wellbutrin XR (a medication used for depression) 150 mg PO every morning, and Zoloft (a medication for depression) 100 mg PO every night, were all marked to be discontinued for MD #1's discretion.

On 8/21/18 a verbal order written by RN #1 at 12:00 a.m. revealed that an order was received from an on-call provider for Abilify 5 mg, Wellbutrin 150 mg, and Zoloft 100 mg until officially reviewed by the psychiatric nurse.

A review of medication informed consent revealed that Patient #1's parent gave consent for the administration of Abilify 5mg PO twice daily, Zoloft 100 mg twice daily, and Wellbutrin 150 PO every morning. The consent was documented on 8/20/18 at 7:30 p.m. by RN #1.

A review of Patient #1's Medication Administration Record (MAR) revealed that Patient #1 received: -

Abilify 5 mg PO twice daily starting 8/21/18- 8/27/18,
Wellbutrin 150 mg PO every morning starting 8/21/18 - 8/25/18,
Zoloft 100 mg PO twice daily given once on 8/21/18, and
Zoloft 200 mg PO every night started 8/22, 8/23, 8/24,8/25, and 8/27.

The medical record failed to reveal that these medications had been ordered and reviewed by an authorized medical provider before being administered to Patient #1.

An interview was conducted with MD #1 on 10/4/18 at 12:14 p.m. in the facility conference room. MD #1 confirmed that he/she was the Psychiatrist in charge of the care of Patient #1. When asked about the medication given to Patient #1 without a signed MD order, MD #1 stated that it is typical to hold a patient's medications overnight so that a doctor can review the medication and confirm the patient's compliance with the medication. MD #1 further stated that some medications cannot be stopped abruptly. When asked about the verbal order given by the on-call physician on 8/21/18 to RN #1 at 12:00 a.m. for Abilify 5mg, Wellbutrin 150 mg, and Zoloft 100 mg, MD #1 stated that if she did not agree with the order she would have discontinued the medications. MD #1 stated it is her practice to only change the order if she disagreed with the on-call physician's order. MD #1 stated she evaluated Patient #1 following the order on 8/21/18 but confirmed that the evaluation was neither signed by MD #1 nor NP #2.

During a tour of the facility on 10/4/18 at 1:47 p.m. an interview was conducted with LPN #9 in the adolescent unit's medication room. LPN #9 stated if he/she received a medication order without a specific timeframe he/she would call the physician to receive clarification or a new order.

A phone interview was conducted with RN #3 on 10/5/18 at 9:31 a.m. RN #3 stated that if he/she received an order that needed clarification he/she would call the provider back to receive clarification on the order that was received. RN #3 stated that regular admission orders do not come with a medication reconciliation form. That form as usually added to the record after admission. Medication orders are faxed to the pharmacy then transcribed onto a blue MAR until consent is received from the patient's parents. Once the consent is received the order is transcribed onto a green MAR and requires two (2) signatures for confirmation.

An interview was held with the CEO and CNO on 10/5/18 at 10:20 a.m. in the facility's conference room. The CEO and CNO #8 both confirmed that Patient #1's chart did not have a provider signature on Patient #1's discharge summary, and progress notes dated 8/21, 8/23, and 8/24.

A review of Medical Staff Rules and Regulations reviewed 1/2018 revealed that the attending physician shall assume and accept full responsibility for the quality of the clinical care of his/her patients. The discharge summary is to be completed by the physician is to be completed within 15 days of discharge. At 30 days post discharge any discharge summary not completed will be considered delinquent. Chapter VII referring to medical records states documentation by physicians shall adhere to the hospital's policies and procedures, standards of the joint commission, CMS, and the State of Georgia. All orders are given by a member of the medical staff and authenticated within 48 hours, except for seclusion and restraint orders which must be authenticated within 24 hours. Verbal orders are encouraged to be restricted to emergencies. In relation to progress notes, the following is expected:

1.) The physician is required to document a progress note at a minimum of once weekly.
2.) Are to be made by the practitioner after each visit with the patient. The practitioner makes six visits a week.
3.) Should give at a minimum the patient's current condition, rationale for changes in diagnosis, changes in medications and/or treatment, justification for continued treatment, justification for continued treatment and description of interventions.

In the medical records physicians must have legible signatures that are dated and timed.

A review of facility policy titled Written Medication Orders that was effective 1/17 revealed that practitioners shall include in the order:

1) Drug name, strength, indication, and direction for use.
2) Signature with date and time.
3) Shall ensure that the order includes the patient's name and room number.
4) If writing a prescription for out-patient it also needs to include quantity to be dispensed, practitioners address and DEA (drug enforcement agency) identification code, and the patient's address.