HospitalInspections.org

Based on a review of documentation, the facility failed to protect the patient's right to request or refuse treatment, as the patient received medications without a dated or timed consent form.

Findings were:

During a review of 10 clinical records, 1 of 10 patients (patient #1) received psychoactive medications for which there was no dated or timed consent form.

Patient #1 was prescribed Remeron, Seroquel and Vistaril by her treating physician. She signed psychoactive medication consents for Remeron and Seroquel but refused to consent to Vistaril. Although patient #1 signed the consents for Remeron and Seroquel, the forms were neither timed nor dated to indicate when they were signed. The forms also lacked the signature of the treating physician, required within 2 working days of the patient receiving explanation of the medications. The patient received doses of both Remeron and Seroquel throughout her stay, beginning on 9-23-17.

Facility policy 111.5 titled "Psychoactive Medications, Patient Consent" states, in part:
"Statement of Purpose: to protect patient's right(sic) to consent to treatment with psychoactive medications and to comply with the requirements of the Texas Administrative Code, and the Texas Health and Safety Code relating to psychoactive medications with consent.
I. Policy
...
E. In the physician's absence, a RN [registered nurse] or RPh [registered pharmacist] will discuss the administration of psychoactive medications with the patient for whom such medication is prescribed according to the guidelines stated in #B. The physician is required to confirm the explanation with the patient and/or the patient's legally authorized representative, if the representative is available, within two (2) working days, not including weekends or holidays. The confirmation by the physician is documented by the(sic) signing the consent form in the appropriate space.
F. Informed consent for the administration of psychoactive medication will be evidenced by a completed copy of the 'Consent for Treatment with Psychoactive Medication' forms ..."

The above was confirmed in an interview with the Chief Nursing Executive and other administrative staff the afternoon of 12-4-17.