HospitalInspections.org

Based on record review and interview the facility failed to administer medication in accordance with federal and state laws, and the approved medical staff policies and procedures for 1 of 10 (Patient #1) patients.

Findings included:

Patient #1 was administered Zyprexa 2.5 mg IM (intramuscularly) on 08/06/24 at 01:35 AM. The medical record did not evidence why the order was necessary, What less intrusive forms of treatment were tried or rejected. What was the patients response to the medications.

During an interview on 09/26/24 at 12:20 PM Personnel #1 and Personnel #2 verified the above findings.

25 Texas Administrative Code Chapter 414, Rule 414.410 reflected
b) If a physician issues an order to administer psychoactive medication to a patient without the patient's consent because of a psychiatric emergency, then the physician will document in the patient's clinical record in specific medical or behavioral terms:
(1) why the order is necessary:
(2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and
(3) the reasons those treatments were rejected.
The policy titled Medication Administration Revised 02/2024 reflected..."PRN (as needed) Medication Administration Guidelines...Effect of PRN medication must be documented within one hour of medication administration..."