The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HICKORY TRAIL HOSPITAL 2000 N OLD HICKORY TRAIL DESOTO, TX 75115 Sept. 7, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview the hospital failed to ensure the right of one of one patient (Patient #1) and/or her representative to make informed decisions regarding Patient #1's care. Patient #1, a minor, received two doses of increased medication without the representative's consent.


Findings included:


Patient #1's Physician's Order Sheet dated 08/03/16 at 1400 reflected to increase Patient #1's Abilify medication (antipsychotic medication) to 5 milligrams by mouth at night.

Patient #1's Interdisciplinary Progress Note dated 08/04/16 at 1954 reflected Patient #1's representative "...called and informed the nurse that the Patient's Abilify should not be increased from 2.5 milligram..."

The hospital Medication Administration Record dated 08/03/16 at 2100 and 08/04/16 at 2100 reflected Patient #1 received Abilify 5 milligrams.

The Medical Administration Record dated 08/05/16 reflected Patient #1's representative refused consent and wanted the dose to be 2.5 milligrams.

During a telephone interview on 09/08/16 at 15:39 Personnel #4 stated that "it was a medication error on our part if ...[Patient #1] did not receive the medication of 2.5 milligrams of Abilify and received the 5 milligrams."

The hospital policy titled Medication Administration Inpatient or Day Patient Record, dated 08/2015 reflected, "The facility shall define and approve licensed independent practitioners and the clinical staff disciplines that are authorized to administer medications...double check the order..."