HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure patients had the right to make informed decisions regarding his or her care.

Findings included:

Review of patient #3's chart revealed Patient #3 had admission orders that stated in part, "Zyprexa 10 mg IM [milligrams intramuscular] q 6º prn severe agitation [every six hours as needed for severe agitation]."
Nursing note dated 7/6/17 at 11:16 pm stated in part, "[Patient] is extremely agitated. Instructed medication nurse to medicate Client with Zyprexa 10 mg IM now.

There was no documentation stating why the order was necessary, other generally accepted, least restrictive forms of treatment, if any, that the physician has evaluated but rejected and the reasons those treatments were rejected. There was no documentation of consent by patient #3 for this administration.


Review of patient #4's medical record revealed admission orders that stated in part, "Zyprexa 10 mg IM and Ativan 2 mg IM q 6º severe agitation."

Nursing note dated 7/22/17 at 2:47 pm stated in part, "Client has been staring at the wall and pacing back and forth in the day room the majority of the day. When someone talks to her she doe [sic] not respond but stares in to [sic] the eyes of the other person as if she can not [sic] hear or see them. Client deliberately approached two other clients who were playing a game and pushed the checkers off into the floor. She willingly took a shot of Zyprexa 10 mg and Ativan 2 mg IM to the left deltoid."

There was no documentation found stating why the order was necessary, other generally accepted, least restrictive forms of treatment, if any, that the physician has evaluated but rejected and the reasons those treatments were rejected. There was no documentation of patient consent or the psychiatrist evaluation before or after an emergency administration of a psychoactive medication.


Patient #4 received the same IM medications on 7/23/17 at 6:00 pm without any documentation on why the patient received the medication, other least restrictive forms of treatment, if any, that the physician has evaluated but rejected and the reasons those treatments were rejected.

The consent for Ativan for patient #4 was signed on 7/24/17 at 11:00 pm, after the patient had received three doses of the medication and it did not specify the route of administration.

The consent for Zyprexa for patient #4 was signed on 7/24/17 at 11:00 pm and was signed for the scheduled dose twice a day.

The above was verified in an interview with staff #1 on the afternoon of 8/22/17.