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CROSS CREEK HOSPITAL 8402 CROSS PARK DRIVE AUSTIN, TX 78754 Jan. 15, 2021
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on a review of facility documentation and staff interviews, the facility failed to ensure informed consent was secured prior to the administration of psychoactive medications for 1 of 10 patients [Patient #1].

Findings were:

Facility policy #MM 002 entitled "Psychoactive Medication Consents," last reviewed/revised 5/2020, included the following:
"All patients who have psychotropic medication ordered and legal representatives of patients who have psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication.
Except in emergency situations or cases of court ordered medication, informed consent will be obtained prior to administering psychotropic medication ...
Informed consent will be secured prior to the initial dose of medication except in an emergency ..."
A review of the medical record of Patient #1 revealed a medication list obtained from her living facility upon admission which included Citalopram (Celexa), Mirtazapine (Remeron) and lamotrigine (an anti-convulsant sometimes used for mood stabilization). Physician admission orders included continuation of these medications. Ms. Martin received doses of citalopram on 1/11/21 and 1/12/21. She received mirtazapine on 1/10/21 through 1/12/21. She was also administered Seroquel (an anti-psychotic) on 1/12/21. Then the doses appear to have ended. Informed consent forms were completed on 1/14/21 at 8:45 a.m. with the note, "Verbal consent [name of son and medical power of attorney for Patient #1] ..."

In an interview with Staff #1, Director of Quality, on the afternoon of 1/15/21 in the hospital conference room, she stated, " ...We had to know he [son of Patient #1] was the medical power of attorney, and we had to know he was who he said he was. That just took a little bit of time to verify and get in order. She came in on a Sunday ..."

The above findings were confirmed in the exit conference with the facility administrative staff.