HospitalInspections.org

Based on document review and interview, for 2 of 4 records (Pts. #2 and #6) reviewed of patients receiving psychotropic medications, the Hospital failed to ensure that informed consent was obtained prior to administration of ordered routine psychotropic medications.

Findings include:

1. The Hospital's policy titled, "Consent for Psychotropic Medication Administration" (revised 01/2025), was reviewed and required, "...The Attending Psychiatrist or designee discusses with the patient/guardian the indication, benefits, risks, side effects, alternative treatments to and the patient's right to refuse psychotropic medication prior to giving an order for psychotropic medication. Patient / guardian consents to psychotropic medications by signing the form witnessed by a member of the multidisciplinary team..."

2. The clinical record of Pt. #2 was reviewed on 12/22/2025 at approximately 12:45 PM. Pt. #2 was admitted on 12/18/2025 with a diagnosis of catatonia (a severe neuropsychiatric disorder characterized by abnormal movement, behavior, and communication, often requiring prompt treatment to prevent serious complications) and schizophrenia (a serious mental health condition that affects how people think, feel and behave). The patient was ordered and administered psychotropic medications including mirtazapine (Remeron) and olanzapine (Zyprexa) starting from 12/19/2025; however, the "Consent for Psychotropic Medication Administration" form, signed by the Nurse on 12/18/2025, had "Refused" written under the patient's signature.

3. The clinical record of Pt. #5 was reviewed on 12/22/2025 at approximately 12:55 PM. Pt. #6 was admitted on 12/18/2025 with a diagnosis of suicidal ideation. The patient was ordered and administered psychotropic medications including paroxtetine (Paxil), lamotrigine (Lamictal), Quetiapine (Seroquel), and topiramate (Topamax) starting from 12/20/2025; however, the record lacked a patient signed consent form for administration of the psychotropic medications.

4. An interview was conducted with the Charge Nurse (E#8) on 12/22/2025, at approximately 12:55 PM. E#8 stated that patients do have the right to refuse medications. E#8 stated that if a patient refuses to sign the psychotropic medication consent, they can't administer psychotropic medications until they do consent. E#8 stated that they can give as needed emergency medications to the patient if they become a danger to self or others. E#8 stated that both the doctor and the nurse approach the patient to explain the medication purpose and effects in order to obtain consent.