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ABILENE BEHAVIORAL HEALTH LLC 4225 WOODS PLACE ABILENE, TX June 17, 2014
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient had the right to make informed decisions regarding his or her care or treatment as psychoactive medications were administered prior to informed consent being given by the patient.

Findings were:

A review of facility patient clinical records revealed that for 4 of 10 patients prescribed psychoactive medications [Patients #1, 2, 9 and 11], a consent for treatment with that medication was either signed after the first dose was given to the patient, or was not available at all.

Patient #1 received a dose of Seroquel XR on the evening of 9/17/13. A Psychoactive Medication Consent for Seroquel XR was signed by the patient on 9/18/13.

Patient #2 received a dose of Klonopin on 6/4/14 at 9:00 a.m. A Psychoactive Medication Consent for Klonopin was signed by the patient on 6/4/14 at 12:50 p.m. She was also given a dose of Zoloft on 5/30/14, yet the facility could provide no documented evidence that she had ever been informed about the medication or given consent to receive it.

Patient #9 received a dose of Luvox on 6/9/14 at 9:00 a.m. A Psychoactive Medication Consent for Luvox was signed by the patient on 6/9/14 at 11:15 a.m.

Patient #11 received a dose of Cymbalta on 6/3/14 at 9:00 a.m. A Psychoactive Medication Consent for Cymbalta was signed by the patient on 6/3/14 at 11:15 a.m.

A review of facility policy entitled Patient Consent for Psychoactive Medication, last revised 9/13, revealed in part:
"It is the intent of the Abilene Behavioral Health to protect and respect the rights of voluntary and involuntary patient with regard to administration of psychoactive medications...
PROCEDURE:
1. Before administration of psychoactive medication to a patient, the treating physician must assure than an explanation has been given to the patient or the patient's legally authorized representative, for each ...psychoactive medication that is ordered.
2. ...This explanation may be given by the registered nurse or licensed vocational nurse, but the treating physician must confirm that the explanation has been given to the patient or the patient's legally authorized representative within two working days, not including weekends or legal holidays...
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7. No psychoactive medication will be administered at Abilene Behavioral Health without completion of the informed consent process with the exception of administration of psychoactive medication in the event of an emergency situation...
8. Nursing staff are to assure that the informed consent process, and all relevant documentation for ...psychoactive medication prescribed, have been completed prior to administration of psychoactive medication. When such assurance has been made the nurse will initial the correct space of the MAR (medication administration record) signifying that it is appropriate to administer the medication.
9. A patient's refusal or attempt to refuse to receive psychoactive medication, whether given verbally or by other indications or means..., will be documented in the progress notes of the patient ' s medical record..."

In an exit conference with the Chief Executive Officer and other administrative staff on the afternoon of 6/17/14 in the facility conference room, all individuals present stated agreement that the consents were found to be as discussed above for each of the four patients mentioned.