HospitalInspections.org

Based on interview and record review it was determined that the hospital failed to ensure 1 of 11 patients (Patient #1's) Guardian was informed regarding the use of a transport jacket and the administration of IM (intramuscular) psychoactive medication prior to transport to the State Hospital.

Findings Included:

(Patient #1's) History and Physical dated 07/30/14 reflected, "Aggressiveness, cognitive decline, history of frontal lobe stroke..."

The Memorandum of Transfer dated 08/19/14 timed at 1800 reflected, "(Patient #1) was accepted by...(State Hospital)...van transport."

The 08/20/14 physician's orders reflected, "Patient needs strait jacket (transport jacket)..."

The 08/20/14 physician's orders timed at 1645 reflected, "Haldol 10 mg (milligrams), Ativan 2 mg and Benadryl 50 mg IM now."

The MAR (medication administration record) dated 07/29/14 through 08/20/14 reflected, "On 08/20/14 at 1645 (Patient #1) was administered Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg now."

The multi-disciplinary noted dated 08/20/14 revealed no documentation indicating the Guardian was contacted regarding the psychoactive medication administration and/or the use of a transport jacket.

The Letter of Guardianship from the State of Texas revealed, "On the 11th day of October, 2011 the appointee having taken the oath prescribed by law is duly qualified and fully legally authorized and empowered to act as the Guardian of the above named person & estate...expires 02/11/15."

On 11/06/14 at 1040 Personnel #1 was interviewed. Personnel #1 was asked by the surveyor to review (Patient #1's) medical record. Personnel #1 stated she did not find any documentation in the medical record which indicated the Guardian was informed regarding the transport jacket and/or regarding the administration of the Haldol, Benadryl and Ativan given to (Patient #1) prior to transport to the State Hospital. Personnel #1 stated the Guardian should have been notified.

The policy and procedure entitled, "Restraint/Seclusion" with an edit date of 07/2014 reflected, "The date and time of the notification of the family member/guardian will be noted..."

The policy and procedure entitled, "Patient Rights and Responsibilities" with an edit date of 01/2013 reflected, "Adult patient with Guardians...Guardians are required to approve admission and treatment of patients."