HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 clinical record (Pt #1) reviewed for informed consent for psychotropic medication, the Hospital failed to ensure that Pt #1 or his representative was involved in care planning or treatment by not ensuring that Pt #1 or his representative was informed regarding antipsychotic medication administration.


Findings include:

1. On 9/13/2021, the Hospital's policy titled, "Patients' Rights and Responsibilities" (reviewed 3/23/2020) was reviewed and required, "...Patients or surrogate decision makers will be provided information about patient's treatment...The information will include - proposed treatments..."

2. On 9/13/2021, Pt #1's clinical record, dated 7/22/2021 to 7/31/2021, was reviewed and indicated:
-Pt #1 was admitted to the Hospital on 7/22/2021 with diagnoses of lip swelling, agitation, alcohol abuse, high blood pressure and alcohol withdrawal syndrome with delirium.
-Physician notes, dated 7/24/2021, noted, "[Pt #1] does not at this time demonstrate the capacity to make decisions about his treatment"...order dated 7/24/2021 included, "Seroquel (antipsychotic medication) 25 mg 2 times daily."
-Pt #1's MAR (medication administration record), dated 7/22/2021 to 7/31/2021, noted that Pt #1 received Seroquel 25 mg twice a day on 7/28/2021 and 7/29/2021. There was no documentation that Z1 (Pt #1's healthcare power of attorney) was contacted for medication information and approval.

3. On 9/13/2021 at 1:10 PM, an interview was conducted with the Physician (MD #1). MD #1 stated that generally MD #1 would discuss what medication a patient is taking and the course of treatment for the patients. MD #1 stated that he does not know if this discussion took place with Pt #1's representative.

4. On 9/14/2021 at 9:15 AM, an interview was conducted with the Registered Nurse (E #6). E #6 stated that family members should be informed regarding the purpose and side effects of psychotropic medications.