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HCA HOUSTON HEALTHCARE SOUTHEAST 4000 SPENCER HWY PASADENA, TX 77504 Aug. 14, 2013
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure patient made informed decisions regarding their treatment. Facility failed to instruct the patients about psychoactive medications administered prior to giving the medications for 7 of 12 sampled patients (ID #s 1, 4, 6, 8, 9, 10 & 11). This deficient practice has the potential to affect all patients preventing them from making informed decisions about their care and exercising their right to request or refuse treatment.

Findings:

Review of medical records for patients (ID #s 1, 4, 6, 8, 9, 10 & 11) revealed that the following psychoactive medications were ordered and administered. Informed consent forms for the medications required prior to the administration of these medications were not completed as required under state law (25 TAC 405.804(a)), and the facility ' s policy and procedure.

Review of Physician Orders and Medication Administration Record (MAR) for the following patients revealed:

Patient ID#1 admitted on [DATE] and discharged on [DATE] received Lamictal 25mg by mouth (PO) at bedtime. Medication was ordered and started 5/30/13 at 9:00pm. No informed consent for medication in patient ' s medical record.

Patient ID# 4 admitted on [DATE] received the following medications without informed consent:
Geodon 80mg PO twice daily was ordered 8/10/13 and started same day.
Abilify 5mg PO daily was ordered 8/8/13 and started 8/9/13
Ambien 5mg PO at bedtime was ordered 8/4/13 and given from 8/4/13

Patient ID# 6 admitted on [DATE] received the following medications:
Seroquel 800mg PO at bedtime was ordered and started on 8/9/13.
Effexor 225mg PO daily was ordered and administered on 8/10/13.
Paxil 25mg PO daily was ordered and started 8/10/13.
Consents for the medications were completed on 8/13/13.

Patient ID# 8 admitted on [DATE]: Trazodone 50mg PO at bedtime was ordered 8/2/13 and given from 8/2/13, consent was signed 8/4/13.

Patient ID# 9 admitted on [DATE]:
Zyprexa 10mg PO three times a day was ordered on [DATE] and started same day.
Xanax 0.25mg PO twice daily was ordered 8/8/13 and initiated 8/8/13.
Consents for medications were signed on 8/13/13.

Patient ID#10 admitted on [DATE] and discharged on [DATE]: Lithium carbonate 300mg PO every eight hours and Risperdal 3mg PO at bedtime were ordered on [DATE] and started same day, Informed Consent forms were signed 7/9/13.

Patient ID# 11 admitted on [DATE] and discharged on [DATE] received the following medications without informed consent:
Librium 25mg PO four times a day was ordered on [DATE] and started 7/23/13.
Risperdal 1mg PO twice daily ordered on [DATE] and initiated same day.

Medical Records reviewed with Staff ID# 58. Interview with Staff ID# 58 and Chief Nursing Officer in conference room on 8/24/13, they acknowledged that informed consents should be signed prior to administration of psychoactive medications.

Review of facility ' s policy titled " Informed Consent Medications/Psychoactive " dated April 2011, section " Procedure " read:
(C) " Informed consent is received for each newly ordered medication ... ... "
(F) " The informed consent for medication is documented on the Informed Consent for Medication form. "
(H) " Only those medications that the patient has consented to may be administered. "