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BRYNN MARR HOSP 192 VILLAGE DRIVE JACKSONVILLE, NC 28540 Sept. 15, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on hospital policy review, medical record review, and staff interview, the facility failed to obtain Legally Responsible Person consent for a medication administration in 1 of 2 patients (Patient #3).
The findings include:
Review of hospital policy titled, "Medication Administration", last review date, 05/16/2016, revealed, "...POLICY STATEMENT: The purpose of this policy is to set guidelines and standards for safe medication administration at (Named Hospital)... VII. OBTAINING CONSENT FOR MEDICATION (PSYCHOTROPIC) A. Obtaining consent for medication... 2. It is the responsibility of the nurse on the unit to obtain consent from the legally responsible person (LRP) guardian (sic) of child/adolescent patients. Each psychotropic medication must have consent prior to giving medication..."
Review of hospital policy titled, "Informed Consent and Education for Narcotics & Psychotropic Medication", last review date, 05/16/2014, revealed, "POLICY STATEMENT: To provide the healthcare providers with documented evidence that the patient/legally responsible person (LRP) gave consent for treatment with narcotic and psychotropic medication... DEFINITIONS... Psychotropic Medications: A medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness... Procedure... 3. Documentation of Informed Consent: A completed copy of the consent form is evidence of informed consent for the administration of narcotic and psychotropic medication... 4. Any time a medication is discontinued and restarted at a later time, a new consent will be obtained..."
Review of the closed medical record review of Patient #3 revealed Vyvanse (a psychotropic medication) was prescribed and initiated, with LRP consent on 08/27/2016, then discontinued on 08/29/2016. Review revealed Vyvanse was resumed on 09/01/2016. Review revealed there was no documented LRP consent for Vyvanse to be resumed.
Staff interview conducted on 09/13/2016 at 1550 with Administrative Staff #1, revealed no documented evidence could be found for LRP consent for the medication Vyvanse being restarted. Interview revealed hospital policy was not followed.
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