HospitalInspections.org

Based upon record review and interview, the facility failed to follow its own policy for informed consent Medications for 18 (#1-#12), #14, #15, (#17- 20) of 20 patients reviewed. There was no evidence that patients were supplied with written education information about the psychoactive medication and the Physician failed to document in the progress notes his/her discussion with the patient about the medication.

Review of the policy titled "Informed Consent for Medications", last reviewed and revised 12/2014, revealed the following:


POLICY:
Patient is to sign consent for psychotropic medications prescribed within treatment of psychiatric illness or psychiatric symptoms. It is the responsibility of the physician to inform, educate and obtain consent either verbally or in writing from the patient or guardian. Information provided to the patient will include expected actions, risks and benefits of the medication.
PROCEDURE:
1. The nurse on the unit will discuss prescribed psychotropic medications with the patient at the time of admission or at the time a new medication is ordered.
1.1 The discussion will include both the benefits and risks involved in taking the medications. 1.1.1 The discussion will be based on written medication information sheets generated and approved by US Pharmacopoeias Drug Information approved sources.
1.1.2 The nursing staff on the unit will obtain and witness the patient ' s written consent to take psychotropic medications.
1.1.3 Written medication education sheets will be given to the patient.
1.2 The nurse will document this on the Medication Consent form.
2. The Physician will document his/her discussion in the Progress Notes.
3. The nurse will inform the Physician in the event that the patient refuses to consent to take prescribed medications.
4. The nurse gives the same information to the /guardian as is given to the patient as discussed earlier. 4.1 When guardian is not available and telephone consent is obtained the following shall occur: 4.1.1 Notation will be made on the medication education sheet: " telephone consent for the following medications obtained from (guardian name) on (date) " .
4.1.2 The licensed staff member who supplied the information regarding prescribed medications will sign the statement.
4.1.3 The guardian will countersign the document when they come in.
4.1.4 A second licensed staff member will witness the phone approval of the guardian.
5. The nurse or physician will follow the process when medications are changed or added to those medications for which patient, or as appropriate conservator/guardian, have given consent: 5.1 Licensed nursing staff member, physician or pharmacist will supply the patient or conservator/guardian with benefit risk information about the new medication.

Review of medical record for patients #1-12, #14, #15, #17-#20 revealed there was no documentation in the physician progress notes that the physician had a discussion with the patient or the patients LAR (legal authorized representative). The only evidence of the physician's involvement in the education of the prescribed medication was the physician's sigature at the bottom of the consent form that was incomplete.

The records also failed to provide evidence that the patients were given written education information about the medication. Review of the "Medication Education and Consent Form" revealed the following information:

Please read this form carefully. If you have any problem reading it, ask to have it read to you.
Dr. (to be identified by nursing staff) Talked with me regarding the following issues concerning me (the patient);
1. The nature of my (patient's) mental, emotional or behavioral problem (s).
2. The reason that the medication (s) may be helpful in treatment, including the likelihood of improving or not improving without them. I am aware there(sic) other forms of treatment. I understand I (patient) may take medication and still be involved in other treatment methods.
3. The Doctor told me the medications group (s), the medication name (s), method of administration, estimated length of treatment, and the side effects that may occur to me(patient).
Neuroleptics
Mood Stabilizers
Antidepressants
Benzodiazepines
Narcotics
(There was a blank space on the page after the last medication group)

Medication to be given with Black Box Labels (listings of medication on Back) (a blank line to be completed by the staff followed this statement)
4. A possible side effect of some neuroleptic medication is Tardive Dyskinesia. The side effect may manifest as persistent involuntary movement of the face/mouth, or a times, the hands and feet.
5. Medication (s) may be prescribed outside the FDA (Food and Drug Administration) guidelines.
6. Medication (s) may interfere with safe operation of machinery, including driving.
7. I can, at any time, ask for more information about my (my patient's) medication(s).
8. I have the right to accept or decline medication(s) ordered for me (my patient)." "I understand, however, certain circumstances, such as when the emergency situations occur, medications may be given me (my patient) without consent.
9. By signing this form, I am authorizing consent to be treated (for my patient to be treated) with the medication(s) listed above. I understand the information contained in this form and have received and reviewed all the information I desire concerning this above listed medication(s).
10. Written information on the medications list was given to patient/guardian.
Oral information not given because: (free space for staff comments)
Written information not given because": (free space for staff comments)

Patient (patient/guardian) signature and date
Physician signature and date.
Witness signature and date"

During exit conference on 11/18/15 at approximately 3:30 pm, the Vice President of Nursing for the corporation confirmed the staff needed more education on providing the required education and documentation related to psychoactive medications.

Based on record and document review, the facility failed to:
A. provide the necessary psychiatric nursing assessments according to the facility ' s policy in 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) of 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) records reviewed.
B. provide the necessary medical nursing assessments according to the facility's policy in 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) of 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) records reviewed.

A. The facility's nursing staff work 8 hour shifts. There are 3 shifts per 24 hour period that cover the periods of 7:00 a.m. until 3:00 p.m., 3:00 p.m. until 11:00 p.m. and, 11:00 p.m. until 7:00 a.m. Each shift nurse should have performed and documented a psychiatric nursing assessment on each patient.
Review of patient #9's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #9 during 9 of the 26 shifts.
Review of patient #10's record revealed the patient was admitted to the facility for a total of 27 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #10 during 9 of the 27 shifts.
Review of patient #11's record revealed the patient was admitted to the facility for a total of 55 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #11 during 19 of the 55 shifts.
Review of patient #13's record revealed the patient was admitted to the facility for a total of 39 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #13 during 18 of the 39 shifts.
Review of patient #14's record revealed the patient was admitted to the facility for a total of 34 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #14 during 10 of the 34 shifts.
Review of patient #15's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #15 during 11 of the 26 shifts.
Review of patient #17's record revealed the patient was admitted to the facility for a total of 16 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #17 during 10 of the 16 shifts.
Review of patient #19's record revealed the patient was admitted to the facility for a total of 17 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #19 during 9 of the 17 shifts.
Review of patient #20's record revealed the patient was admitted to the facility for a total of 30 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #20 during 13 of the 30 shifts.
Review of the facility's policy titled: "Reassessment of the Patient" revealed the following information:
"POLICY: ...
2. The psychiatric elements of the patient's condition will be evaluated at a minimum of once per shift, or more often, as indicated per the patient situations ...."


B. The facility's nursing staff work 8 hour shifts. There are 3 shifts per 24 hour period that cover the periods of 7:00 a.m. until 3:00 p.m., 3:00 p.m. until 11:00 p.m. and, 11:00 p.m. until 7:00 a.m. At a minimum, the day shift (7:00 a.m. until 3:00 p.m. shift) and the evening shift (3:00 p.m. until 11:00 p.m. shift) nurses should have performed and documented a medical nursing assessment on each patient.
Review of patient #9's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. 17 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #9 during 3 of the 17 day and evening shifts.
Review of patient #10's record revealed the patient was admitted to the facility for a total of 27 (8 hour) shifts. 18 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #10 during 4 of the 18 day and evening shifts.
Review of patient #11's record revealed the patient was admitted to the facility for a total of 55 (8 hour) shifts. 37 of the 55 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #11 during 10 of the 37 day and evening shifts.
Review of patient #13's record revealed the patient was admitted to the facility for a total of 39 (8 hour) shifts. 25 of 39 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #13 during 13 of the 25 day and evening shifts.
Review of patient #14's record revealed the patient was admitted to the facility for a total of 34 (8 hour) shifts. 23 of 34 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #14 during 11 of the 23 day and evening shifts.
Review of patient #15's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. 18 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing shift assessment was EVER completed on patient #15 during his stay at the facility.
Review of patient #17's record revealed the patient was admitted to the facility for a total of 16 (8 hour) shifts. 10 of the 16 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #17 during 8 of the 10 day and evening shifts.
Review of patient #19's record revealed the patient was admitted to the facility for a total of 17 (8 hour) shifts. 11 of the 17 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #19 during 8 of the 11 day and evening shifts.
Review of patient #20's record revealed the patient was admitted to the facility for a total of 30 (8 hour) shifts. 20 of the 30 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #20 during 6 of the 20 day and evening shifts.
Review of the facility ' s policy titled: "Reassessment of the Patient" revealed the following information:
"POLICY: ...
2 ....The medical assessment shall be completed on the day and evening shift, or more often, as indicated by the patient situations ..."

Based on record and document review, the facility failed to ensure nursing staff obtained a physician's order for all medications administered in 7 (patient #12, #13, #15, #16, #21, #22, #23) of 7 (patient #12, #13, #15, #16, #21, #22, #23) medication error incident report records reviewed.
Review of the facility's "Health Incident Review Reports" for the dates of 10/03/2015 through 11/11/2015, revealed 8 incident reports of medications being removed from the facility's Pyxis System (automated medication dispensing system) for a specific patient that did not have a physician's order for the medication.
Review of "Health Incident Review Report" for patient #12 revealed on 10/03/2015 at 6:29 p.m., staff #19 removed Diphenhydramine 50 mg (milligram) capsule, Haloperidol 5 mg tablet, and Lorazepam 2 mg tablet from the Pyxis System for patient #12. Review of patient #12's record revealed there was NOT a physician's order written for the medications.
Review of "Health Incident Review Report" for patient #13 revealed on 10/20/2015 at 4:50 p.m., staff #19 removed Diphenhydramine 50 mg (milligram) injectable, Haloperidol 5 mg injectable, and Lorazepam 2 mg injectable from the Pyxis System for patient #13. Review of patient #13's record revealed there was NOT a physician's order written for the medications.
Review of "Health Incident Review Report" for patient #15 revealed on 10/15/2015 at 10:37 p.m., staff #20 removed EC ASA (Enteric Coated Aspirin) 325 mg from the Pyxis System for patient #15. Review of patient #15's record revealed there was NOT a physician's order written for the medication.
Review of "Health Incident Review Report" for patient #16 revealed on 10/13/2015 at 4:16 p.m., staff #21 removed Neosporin Ointment from the Pyxis System for patient #16. Review of patient #16's record revealed there was NOT a physician's order written for the medication.
Review of "Health Incident Review Report" for patient #21 revealed on 10/20/2015 at 8:40 p.m., staff #21 removed Vistaril 50 mg capsule from the Pyxis System for patient #21. Review of patient #21's record revealed there was NOT a physician's order written for the medication.
Review of "Health Incident Review Report" for patient #22 revealed on 11/01/2015 at 10:41 a.m., staff #22 removed Guaifenesin/Dextromethorphan (Robitussin DM) 10 ml (milliliter) from the Pyxis System for patient #22. Review of patient #22's record revealed there was NOT a physician's order written for the medication.
Review of "Health Incident Review Report" for patient #23 revealed on 11/02/2015 at 2:50 p.m., staff #23 removed Phenytoin 100 mg capsule from the Pyxis System for patient #23. Review of patient #23's record revealed there was NOT a physician's order written for the medication.

Based on record and document review, the facility failed to:
A. provide the necessary psychiatric nursing assessments according to the facility ' s policy in 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) of 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) records reviewed.
B. provide the necessary medical nursing assessments according to the facility's policy in 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) of 9 (patient #9, #10, #11, #13, #14, #15, #17, #19 and #20) records reviewed.

A. The facility's nursing staff work 8 hour shifts. There are 3 shifts per 24 hour period that cover the periods of 7:00 a.m. until 3:00 p.m., 3:00 p.m. until 11:00 p.m. and, 11:00 p.m. until 7:00 a.m. Each shift nurse should have performed and documented a psychiatric nursing assessment on each patient.
Review of patient #9's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #9 during 9 of the 26 shifts.
Review of patient #10's record revealed the patient was admitted to the facility for a total of 27 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #10 during 9 of the 27 shifts.
Review of patient #11's record revealed the patient was admitted to the facility for a total of 55 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #11 during 19 of the 55 shifts.
Review of patient #13's record revealed the patient was admitted to the facility for a total of 39 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #13 during 18 of the 39 shifts.
Review of patient #14's record revealed the patient was admitted to the facility for a total of 34 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #14 during 10 of the 34 shifts.
Review of patient #15's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #15 during 11 of the 26 shifts.
Review of patient #17's record revealed the patient was admitted to the facility for a total of 16 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #17 during 10 of the 16 shifts.
Review of patient #19's record revealed the patient was admitted to the facility for a total of 17 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #19 during 9 of the 17 shifts.
Review of patient #20's record revealed the patient was admitted to the facility for a total of 30 (8 hour) shifts. There was NO documentation a nursing psychiatric assessment was completed on patient #20 during 13 of the 30 shifts.
Review of the facility's policy titled: "Reassessment of the Patient" revealed the following information:
"POLICY: ...
2. The psychiatric elements of the patient's condition will be evaluated at a minimum of once per shift, or more often, as indicated per the patient situations ...."


B. The facility's nursing staff work 8 hour shifts. There are 3 shifts per 24 hour period that cover the periods of 7:00 a.m. until 3:00 p.m., 3:00 p.m. until 11:00 p.m. and, 11:00 p.m. until 7:00 a.m. At a minimum, the day shift (7:00 a.m. until 3:00 p.m. shift) and the evening shift (3:00 p.m. until 11:00 p.m. shift) nurses should have performed and documented a medical nursing assessment on each patient.
Review of patient #9's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. 17 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #9 during 3 of the 17 day and evening shifts.
Review of patient #10's record revealed the patient was admitted to the facility for a total of 27 (8 hour) shifts. 18 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #10 during 4 of the 18 day and evening shifts.
Review of patient #11's record revealed the patient was admitted to the facility for a total of 55 (8 hour) shifts. 37 of the 55 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #11 during 10 of the 37 day and evening shifts.
Review of patient #13's record revealed the patient was admitted to the facility for a total of 39 (8 hour) shifts. 25 of 39 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #13 during 13 of the 25 day and evening shifts.
Review of patient #14's record revealed the patient was admitted to the facility for a total of 34 (8 hour) shifts. 23 of 34 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #14 during 11 of the 23 day and evening shifts.
Review of patient #15's record revealed the patient was admitted to the facility for a total of 26 (8 hour) shifts. 18 of the 26 shifts were day and evening shifts. There was NO documentation a medical nursing shift assessment was EVER completed on patient #15 during his stay at the facility.
Review of patient #17's record revealed the patient was admitted to the facility for a total of 16 (8 hour) shifts. 10 of the 16 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #17 during 8 of the 10 day and evening shifts.
Review of patient #19's record revealed the patient was admitted to the facility for a total of 17 (8 hour) shifts. 11 of the 17 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #19 during 8 of the 11 day and evening shifts.
Review of patient #20's record revealed the patient was admitted to the facility for a total of 30 (8 hour) shifts. 20 of the 30 shifts were day and evening shifts. There was NO documentation a medical nursing assessment was completed on patient #20 during 6 of the 20 day and evening shifts.
Review of the facility ' s policy titled: "Reassessment of the Patient" revealed the following information:
"POLICY: ...
2 ....The medical assessment shall be completed on the day and evening shift, or more often, as indicated by the patient situations ..."