HospitalInspections.org

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Based on record review and interview the facility failed to ensure informed consent processes for the use of psychotropic medications were executed in accordance with State law for one patient (#5) out of 11 sample patients. This failed practice placed the patient at risk for receiving medication against his or her will.

Findings:

Based on record review from 2/11-12/25 of Patient #5's medical record review, dated 11/18/24 to 2/10/25, the patient had diagnoses that included:

-traumatic brain injury (TBI- a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain);

-schizoaffective disorder (a disorder in which the individual suffers from both symptoms that qualify as schizophrenia and symptoms that qualify as a mood disorder such depression or bipolar disorder, for a substantial portion of the active period of the illness, as well as episodes of delusions or hallucinations in the absence of prominent mood symptoms);

-catatonia (a disorder that disrupts a person's awareness);

-borderline intellectual function with a full-scale IQ (FSIQ) below 70 (Suggests significantly below-average intellectual functioning. Often associated with cognitive impairments or developmental delays. Comprehensive support and interventions are typically required.);

-neurocognitive disorder (a medical condition characterized by a decline in cognitive abilities such as memory, thinking, problem-solving, and language skills.); and

-developmental disability (conditions due to an impairment in physical, learning, language, or behavior areas that may impact day to day functioning).

Behavior Plan Review:

Record review from 2/11-12/25 of Patient #5's "Individualized Behavior Plan ...", dated 12/17/24 revealed " ...experiences a severe mental illness and traumatic brain injury - this affects [his/her] memory and attentions span ...[Patient #5] underwent psychological testing for [his/her cognitive function ...[he/she] has difficulties habituating basic skills ...show novel learning...inattention, impulsivity, and distractibility ...[Patient #5] exhibited difficulties habituating more complex skills based on repetition and difficult blending new information ...will need prompting and repetition of simple, single step instructions in order to complete task ..."

Court Document Review:

Record review of Patient #5's medical record revealed the following court documents:

August 2024:

A petition for 90-day commitment, dated 8/20/24, revealed the petitioner alleged that Patient #5 continued to be gravely disabled, and there was reason to believe that the patient's mental condition could be improved by continued course of treatment and was likely to cause serious harm to others. The document further stated that Patient #5 had severe deterioration over the past week secondary to noncompliance with scheduled medications and required previous crisis periods that were attributed to psychosis. An order for 90-day commitment, dated 8/23/24 was granted with an expiration date of 11/18/24.

A petition for 90-day court approval of administration of psychotropic medications, dated 8/21/24, revealed the Patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. The document further stated that Patient #5 had severe deterioration over the past week secondary to noncompliance with scheduled medications and required previous crisis periods that were attributed to psychosis. An order granting administration of psychotropic medication in non-crisis situations for court approval of administration of psychotropic medications, dated 8/23/24 was granted and filed on 8/21/24 with an expiration date of 11/19/24.

November 2024:

A petition for 180-day commitment, dated and filed on 11/18/24, revealed the petitioner alleged that Patient #5 continued to be gravely disabled, and there was reason to believe that the patient's mental condition could be improved by continued course of treatment and remained highly assaultive and unpredictable. The document further stated that when unmedicated, Patient #5 decompensated very rapidly. A stipulation order for 180-day commitment, dated 12/9/24 was granted.

A petition for approval of administration of psychotropic medications, dated and filed on 11/18/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. No court order or stipulation order was granted for this petition.

December 2024:

A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 12/9/24, revealed the Patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process.

Record review of a facility provided email from Legal Staff #1 to Provider #1 and facility leadership and legal counsel, dated 12/9/24, revealed the facility withdrew the medication petition because Attorney #2 stated " ...case ...resolved ...Client will stipulate to 180-day commitment and Provider #1 ...says client is being compliant with [his/her] medications so no hearing on the medication petition is needed today."

Further review of the same email revealed "Provider #1has informed [Legal Staff #1] that he/she wants to file [medication] again and go forward with [medication] hearing ...petition ready to be filed ..."

Record review of a facility provided email from Provider #1 to Legal Staff #1 and facility legal counsel, dated 12/16/24, revealed "[Patient #5] will continue to be compliance but [his/her] public defender does not believe [he/she] has informed consent to agree to [his/her] current medication petition. The medication petition is being requested as the patient has previously been noncompliant during prior ...commitment and as a result had substantial deterioration ..."

During an interview on 2/11/25 at 3:00 PM, Provider #1 stated Attorney #2 did not want to stipulate to medication administration, and he was under the assumption that medication stipulation would be revisited but did not occur. Provider #1 further stated that Attorney #2 filed only for commitment and not psychotropic medications. When asked if Patient #5 was competent to make informed decisions, he stated that Patient #5 didn't understand why he/she was taking medication but will take them. In addition, he stated the Patient had a history of medication noncompliance.

Record review on 2/12/25 of the facility's "Unusual Occurrence Report (UOR)", dated 1/30/25, revealed incident type was a medication issue. Further review revealed "[Provider #2] notified [registered nurse] and unit manager that [Patient #5] doesn't have court order medication despite having a 'court ordered' labeled medication in the [Medication Administration Record MAR] for months..."

January 2025:

A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process.

During an interview on 2/11/25 at 2:33 PM, Provider #2 stated Patient #5 had a history of not taking medications necessary for the safety and well-being of himself/herself or others. Provider #2 further stated that Patient #5 did not have the cognitive capacity to make informed decisions and often confused.

February 2025:

An amended petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. The amended petition was granted on 2/6/25.

During an interview with the facility's attorney on 2/11/25 at 2:14 PM, Attorney #1 stated that if a patient did not have capacity for informed consent, then a petition would be filed for commitment and psychotropic medication if treatment was deemed required.

Medication Administration Review:

Record review from 2/11-12/25 of Patient #5's medical record, dated 12/5/24 to 2/5/25 (63 days) revealed the Patient was prescribed the follow psychotropic medications (medications that affect the mind, emotions, and behavior):

-chlorpromazine (an antipsychotic agent to treat psychotic disorders) as needed for agitation, administered 34 of the 63 days;

-hydroxyzine (a sedative used to treat anxiety) for anxiety, administered 46 of the 63 days;

-lorazepam (a benzodiazepine used to treat anxiety) daily for anxiety, as well as lorazepam as need by mouth, if refused administer intramuscularly (IM) for anxiety, administered oral doses 63 of the 63 days.

Record review from 2/11-12/25 of Patient #5's medication record, dated 12/5/24 to 2/5/25 revealed the Patient refused medication attempts 61 times.

Psychiatric Progress Note Review:

Record review of " ...Psychiatric Progress Note ...", dated 11/18/24, revealed Patient #5 is missing morning medications due to sleeping in.

Record review of " ...Psychiatric Progress Note ...", dated 12/10/24, revealed "needs [medication] court hearing."

Record review of " ...Psychiatric Progress Note ...", dated 1/2/25, revealed Patient #5 pretends to sleep and medication injection was administered.

Record review of " ...Psychiatric Progress Note ...", dated 1/8/24, revealed Patient #5 continues to sleep in during the mornings and made statements about wanting to be compliant with medication all the time.

Record review of " ...Psychiatric Progress Note ...", dated 1/14/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/17/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/23/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/29/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/30/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 2/5/25, revealed events of medication refusal since last encounter.

State Law Review:

During an interview on 2/11/24, the Chief Clinical Officer stated it was the responsibility of the providers to ensure a valid consent was active before ordering the administration of psychotropic medications.

Review of the facility's policy "MS-030-16 Psychotropic Medications and Informed Consent," dated 10/16/24, revealed " ...Alaska Psychiatric Institute (API) will follow Alaska Statutes (AS) 47.30.836 - 47.30.839 in the administration of psychotropic medication ...court ordered medications will be ordered and administered in accordance with state statute."

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed "Sec. 47.30.836. Psychotropic medication in non-crisis situation. (a) An evaluation facility or designated treatment facility may not administer psychotropic medication to a patient in a situation that does not involve a crisis under AS 47.30.838(a)(1) unless the patient (1) has the capacity to give informed consent to the medication, as described in AS 47.30.837, and gives that consent; the facility shall document the consent in the patient's medical chart; or ... (3) is determined by a court to lack the capacity to give informed consent to the medication and the court approves use of the medication under AS 47.30.839."

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed "Sec. 47.30.837. Informed consent. ...(c) If an evaluation facility or designated treatment facility has provided to the patient the information necessary for the patient's consent to be informed and the patient voluntarily consents, the facility may administer psychotropic medication to the patient unless the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions. If the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions and the facility wishes to administer psychotropic medication to the patient, the facility shall follow the procedures of AS 47.30.839.

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed Sec. 47.30.839. Court-ordered administration of medication. (a) An evaluation facility or designated treatment facility may use the procedures described in this section to obtain court approval of administration of psychotropic medication if (1) there have been, or it appears that there will be, repeated crisis situations as described in AS 47.30.838(a)(1) and the facility wishes to use psychotropic medication in future crisis situations; or (2) the facility wishes to use psychotropic medication in a noncrisis situation and has reason to believe the patient is incapable of giving informed consent ..."

Record review on 2/12/25 of the facility provided training entitled "Informed Consent of Psychotropic Medications", last updated 2024, revealed "Psychiatric [Licensed Provider] may seek court approval for administration of psychotropic medication ...Hearing on capacity to give informed consent and best interest of patient."

Review of the facility's policy "PRE-030-02 Patient Rights," dated 1/29/24, revealed "Psychotropic Medications and Informed Consent," dated 10/16/24, revealed "To ensure that the civil and legal rights of patients are not restricted during their stay at the Alaska Psychiatric Institute (API)."

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Based on record review and interview the facility failed to ensure the medical record contained informed consent and/or court order for the use of psychotropic medications under State law for one patient (#5) out of 11 sampled patients. This failed practice placed the patient at risk for receiving medication against his or her will.

Findings:

Review of the facility's policy "IM-050-05.04 Documentation Standards," dated 1/20/22, revealed "The health record reflects patient care and is used: ...As a means of communication among physicians and professional groups; As a means of communication between clinical staff; To reflect and document the quality of care rendered the patient; ...Documentation of the following must be reflected in the applicable EHR template by responsible staff: ...Change in legal status"

Based on record review from 2/11-12/25 of Patient #5's medical record review, dated 11/18/24 to 2/10/25, the patient had diagnoses that included:

-traumatic brain injury (TBI- a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain);

-schizoaffective disorder (a disorder in which the individual suffers from both symptoms that qualify as schizophrenia and symptoms that qualify as a mood disorder such depression or bipolar disorder, for a substantial portion of the active period of the illness, as well as episodes of delusions or hallucinations in the absence of prominent mood symptoms);

-catatonia (a disorder that disrupts a person's awareness);

-borderline intellectual function with a full-scale IQ (FSIQ) below 70 (Suggests significantly below-average intellectual functioning. Often associated with cognitive impairments or developmental delays. Comprehensive support and interventions are typically required.);

-neurocognitive disorder (a medical condition characterized by a decline in cognitive abilities such as memory, thinking, problem-solving, and language skills.); and

-developmental disability (conditions due to an impairment in physical, learning, language, or behavior areas that may impact day to day functioning).

Behavior Plan Review:

Record review from 2/11-12/25 of Patient #5's "Individualized Behavior Plan ...", dated 12/17/24, revealed " ...experiences a severe mental illness and traumatic brain injury - this affects [his/her] memory and attentions span ...[Patient #5] underwent psychological testing for [his/her cognitive function ...[he/she] has difficulties habituating basic skills ...show novel learning...inattention, impulsivity, and distractibility ...[Patient #5] exhibited difficulties habituating more complex skills based on repetition and difficult blending new information ...will need prompting and repetition of simple, single step instructions in order to complete task ..."

Court Document Review:

Record review of Patient #5's medical record revealed the following court documents:

November 2024:

A petition for approval of administration of psychotropic medications, dated and filed on 11/18/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and did not have the capacity to participate in treatment decisions by means of a rational thought process. No court order or stipulation order was granted for this petition.

December 2024:

A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 12/9/24, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process.

Record review of a facility provided email from Legal Staff #1 to Provider #1 and facility leadership and legal counsel, dated 12/9/24, revealed the facility withdrew the medication petition because Attorney #2 stated " ...case ...resolved ...Client will stipulate to 180-day commitment and Provider #1 ...says client is being compliant with [his/her] medications so no hearing on the medication petition is needed today."

Further review of the same email revealed "Provider #1 has informed [Legal Staff #1] that he/she wants to file [medication] again and go forward with [medication] hearing ...petition ready to be filed ..."

Record review of a facility provided email from Provider #1 to Legal Staff #1 and facility legal counsel, dated 12/16/24, revealed "[Patient #5] will continue to be compliance but [his/her] public defender does not believe [he/she] has informed consent to agree to [his/her] current medication petition. The medication petition is being requested as the patient has previously been noncompliant during prior ...commitment and as a result had substantial deterioration ..."

During an interview on 2/11/25 at 3:00 PM, Provider #1 stated the patient's public defender and public advocate did not want to stipulate to medication administration and he was under the assumption that medication stipulation would be revisited but did not occur. Provider #1 further stated that the public defender filed only for commitment and not psychotropic medications. When asked if Patient #5 was competent to make informed decisions, he stated that Patient #5 didn't understand why he/she was taking medication but will take them. In addition, he stated the Patient had a history of medication noncompliance.

Record review on 2/12/25 of the facility's "Unusual Occurrence Report (UOR)", dated 1/30/25, revealed incident type was a medication issue. Further review revealed "[Provider #2] notified [registered nurse] and unit manager that [Patient #5] doesn't have court order medication despite having a 'court ordered' labeled medication in the [Medication Administration Record MAR] for months..."

January 2025:

A petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process.

During an interview on 2/11/25 at 2:33 PM, Provider #2 stated Patient #5 had a history of not taking medications necessary for the safety and well-being of himself/herself or others. Provider #2 further stated that Patient #5 did not have the cognitive capacity to make informed decisions and often confused.

February 2025:

An amended petition for 180-day court approval of administration of psychotropic medications, dated and filed on 1/29/25, revealed the patient did not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts and does not have the capacity to participate in treatment decision by means of a rational thought process. A court order, dated 2/6/25, was granted.

During an interview with the facility's attorney on 2/11/25 at 2:14 PM, Attorney #1 stated that if a patient did not have capacity for informed consent, then a petition would be filed for commitment and psychotropic medication if treatment was deemed required.

As a result, Patient #5 did not have informed consent and/or court ordered for the administration of psychotropic medications from 12/5/24 to 2/5/25 for a total of 63 days.

Medication Administration Review:

Record review from 2/11-12/25 of Patient #5's medical record, dated 12/5/24 to 2/5/25 (63 days) revealed the patient was prescribed the follow psychotropic medications (medications that affect the mind, emotions, and behavior):

-chlorpromazine (an antipsychotic agent to treat psychotic disorders) as needed for agitation, administered 34 of the 63 days;

-hydroxyzine (a sedative used to treat anxiety) for anxiety, administered 46 of the 63 days;

-lorazepam (a benzodiazepine used to treat anxiety) daily for anxiety, as well as lorazepam as need by mouth, if refused administer intramuscularly (IM) for anxiety, administered oral doses 63 of the 63 days.

Psychiatric Progress Note Review:

Record review of " ...Psychiatric Progress Note ...", dated 11/18/24, revealed Patient #5 is missing morning medications due to sleeping in.

Record review of " ...Psychiatric Progress Note ...", dated 12/10/24, revealed "needs [medication] court hearing."

Record review of " ...Psychiatric Progress Note ...", dated 1/2/25, revealed Patient #5 pretends to sleep and medication injection was administered.

Record review of " ...Psychiatric Progress Note ...", dated 1/8/24, revealed Patient #5 continues to sleep in during the mornings and made statements about wanting to be compliant with medication all the time.

Record review of " ...Psychiatric Progress Note ...", dated 1/14/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/17/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/23/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/29/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 1/30/25, revealed events of medication refusal since last encounter.

Record review of " ...Psychiatric Progress Note ...", dated 2/5/25, revealed events of medication refusal since last encounter.

State Law Review:

During an interview on 2/11/24, the Chief Clinical Officer stated it was the responsibility of the providers to ensure a valid consent was active before ordering the administration of psychotropic medications.

Review of the facility's policy "MS-030-16 Psychotropic Medications and Informed Consent," dated 10/16/24, revealed " ...Alaska Psychiatric Institute (API) will follow Alaska Statutes (AS) 47.30.836 - 47.30.839 in the administration of psychotropic medication ...court ordered medications will be ordered and administered in accordance with state statute."

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed "Sec. 47.30.836. Psychotropic medication in non-crisis situation. (a) An evaluation facility or designated treatment facility may not administer psychotropic medication to a patient in a situation that does not involve a crisis under AS 47.30.838(a)(1) unless the patient (1) has the capacity to give informed consent to the medication, as described in AS 47.30.837, and gives that consent; the facility shall document the consent in the patient's medical chart; or ... (3) is determined by a court to lack the capacity to give informed consent to the medication and the court approves use of the medication under AS 47.30.839."

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed "Sec. 47.30.837. Informed consent. ...(c) If an evaluation facility or designated treatment facility has provided to the patient the information necessary for the patient's consent to be informed and the patient voluntarily consents, the facility may administer psychotropic medication to the patient unless the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions. If the facility has reason to believe that the patient is not competent to make medical or mental health treatment decisions and the facility wishes to administer psychotropic medication to the patient, the facility shall follow the procedures of AS 47.30.839.

Record review of the Alaska State Legislature Statutes, dated 2023-2024, revealed Sec. 47.30.839. Court-ordered administration of medication. (a) An evaluation facility or designated treatment facility may use the procedures described in this section to obtain court approval of administration of psychotropic medication if (1) there have been, or it appears that there will be, repeated crisis situations as described in AS 47.30.838(a)(1) and the facility wishes to use psychotropic medication in future crisis situations; or (2) the facility wishes to use psychotropic medication in a noncrisis situation and has reason to believe the patient is incapable of giving informed consent ..."

Record review on 2/12/25 of the facility provided training entitled "Informed Consent of Psychotropic Medications", last updated 2024, revealed "Psychiatric [Licensed Provider] may seek court approval for administration of psychotropic medication ...Hearing on capacity to give informed consent and best interest of patient."
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