HospitalInspections.org

Based on record review and interview, the facility failed to ensure the rights of a patient (Patient #1) to make an informed decision regarding his care, as evidenced by staff not obtaining consent for 4 out of 6 psychoactive drugs prescribed for him.


Findings included:


Review of facility policy titled "Informed Consent for Medication Administration", last reviewed 3/1/24, showed that informed consent for psychoactive medication is required for all patients, must be written, and is part of the medical record. In addition (except in an emergency), psychoactive medications may not be administered to a patient without informed consent.

Record review of Patient #1's clinical records showed there were six psychoactive medication consent forms present for the following drugs: Seroquel, Celexa, Trazadone, Zyprexa, Lithium and Depakote. The consents were done by nurses who filled out the consent forms on 9/1/24. For four of these medications- Seroquel, Celexa, Trazadone and Zyprexa, the consent forms showed that the patient did not sign them or give verbal consent. Instead, telephone verbal consent was obtained from the patient's mother by nurses, and the forms indicated that she was the legal guardian.

Further record review failed to reveal evidence the patient had a legal guardian.

In an interview on 10/8/24 at 3:30 pm, RM-Staff #A stated the patient did not have a legal guardian.

In an interview on 10/9/24 at 10:15 am, PI-Staff #D also stated the patient did not have a legal guardian, and if the patient did have one, it would be in his chart. Also, the legal paperwork related to court commitment present in the chart would show if there was a legal guardian.

During an interview on 10/9/24 at 10:30 am, Intake-Staff #H stated that legal guardianship is usually initially determined during the intake process, and also confirmed that Patient #1 did not have a legal guardian.

In a group interview during exit conference on 10/9/24 at 3:34 pm, Staff #A, B, C, D and #H acknowledged that the consent processes for four of Patient #1's psychoactive medications were not properly executed.