HospitalInspections.org

Based on record reviews and interviews, it was determined the facility failed to follow their Informed Consent Policy and Procedure that would ensure one of one patient's (patient #1) guardian was given the right to make informed decisions regarding consent to the use of psychotropic medications. This had the potential to affect any patient who had a guardian and was placed on psychotropic medications.

Findings included:

Record review on 11/10/14 of Informed Consent Policy and Procedure, last reviewed by facility in February 2011, revealed but was not limited to the following:

"Written Consent: A written consent form is to be used to obtain authorization prior to the procedure or treatment. When completed, the form serves as a record and evidence that the patient authorized the procedure and accepted the associated risks as disclosed by the physician. Persons under Guardianship (adults or minors): All persons under legal custody of a guardian or conservator shall have permits signed by their legal guardian (as guardian) and a certified copy of his/her official letters of guardianship shall be obtained and placed in and become part of the patients' permanent medical record, prior to receiving treatment."

Record review on 11/10/14 of Patient #1's medical record revealed but was not limited to the following: "Annual Report On Condition and Well-Being of Ward and Oath of Guardian signed by Patient's guardian [mother] on 05/07/2014." Patient #1 was documented to have "Mental Retardation" and deemed an Incapacitated person.

Record review on 11/10/14 of Patient #1's medical record revealed Consents for Treatment with Psychotropic Medication for Risperdal, dated 08/09/14, for Depakote Extended Release (ER), dated 08/09/14, and Valium, dated 08/11/14. The consents for Risperdal and Depakote ER documented Patient #1 gave verbal consent. The consent for Valium had Patient #1 signing his first name. The guardian did not sign Consents to Treatment with Psychotropic Medication forms.

Interview on 11/19/14 at 1:30 PM with Social Worker #1 confirmed she was aware that Patient #1 had a guardian. She stated that information is given to the nursing staff by the social work staff and then it is up to the nursing staff to obtain consents from the guardian.