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Based on observation, interview, and record review, the facility failed to ensure the medication consent (the process where a competent patient receives comprehensive information about a proposed medication, including its purpose, benefits, risks, potential side effects, and alternatives, to make a voluntary and informed decision to accept or refuses it) for psychotropic drugs (medications which affect the mind and behavior of a patient by altering the chemical balance in the brain) was signed in accordance with the facility's policies and procedures (P&P), for four of 18 sample patients (Patient 3, 6, 8, and 9), when:

1. For Patient 3, the psychotropic medication consent was not obtained from Patient 3 for the prescribed Lexapro (a medication used to treat mental mood disorders) medication;

2. For Patient 6, the psychotropic medication consent was not obtained from Patient 6 for the prescribed Latuda (a medication used to treat mental health disorders) medication;

3. For Patient 8, the psychotropic medication consent was not obtained from Patient 8 for the prescribed Vistaril (a medication used to treat anxiety [a mood disorder], Trazadone (a medication used to treat anxiety and depression [mood disorders]), and Ativan (medication used to treat anxiety); and

4. For Patient 9, the psychotropic medication consent was not obtained from Patient 9 for the prescribed Vistaril medication.

These failures had the potential for patients to not be aware of the risks and benefits of the prescribed pschotropic medication before they are administered to them, the patients' safety, and violate the patients' rights.

Findings:

1. On September 3, 2025, at 9:21 a.m., a review of Patient 3's record was conducted with the Chief Nursing Officer (CNO). A facility document titled, "INITIAL PSYCHIATRIC EVALUATION," dated July 18, 2025, was reviewed and indicated Patient 3 was admitted to the facility on July 18, 2025, on an involuntary (a legal process which allows a person with a serious mental illness to be admitted to a psychiatric facility for treatment against their will, usually for a limited period) hold for grave disability (when a person is unable to provide for his own basic needs).

A facility document titled, "PRACTITIONER ORDER SHEET," dated July 24, 2025, was reviewed. The document indicated, "...Lexapro 20 [twenty] mg [milligrams, unit of measurement] PO [by mouth] q [every] daily for mood...ordered on 7/24/25 [July 24, 25] at 1100 [11 a.m.]..."

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated July 23, 2025, at 9 a.m., was reviewed. The document indicated, "...LEXAPRO TAB [tablet] 10 MG PO QDAY [daily]...GIVE 1 [one] TAB PO QDAY FOR DEPRESSION [a mood disorder characterized by persistent feelings of sadness and loss of interest]...NEED CONSENT..." The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3.

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated July 24, 2025, at 9 a.m., was reviewed. The document indicated, "...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT..." The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3.

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated July 25, 2025, at 9 a.m., was reviewed. The document indicated, "...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT..." The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3.

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated July 26, 2025, at 9 a.m., was reviewed. The document indicated, "...LEXAPRO TAB 10 MG PO QDAY...GIVE 1 TAB PO QDAY FOR DEPRESSION, NEED CONSENT..." The document indicated the medication nurse placed her initials on the document on July 23, 2025, at 9 a.m., to indicate the medication nurse administered Lexapro to Patient 3.

There was no documented evidence a psychotropic medication consent for Lexapro was obtained from Patient 3.

On September 3, 2025, at 11: 23 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation Patient 3 provided her consent to receive Lexapro. The CNO stated the medication nurse should have verified the consent was signed before administering Lexparo to Patient 3. The CNO stated the medication consent for Lexapro should have been obtained from Patient 3 prior to the administration of Lexapro to Patient 3 since Patient 3 was prescribed the medication.

2. On September 3, 2025, at 9:30 a.m., a review of Patient 6's record was conducted with the CNO. A facility document titled, "INITIAL PSYCHIATRIC EVALUATION," dated May, 30 2025, was reviewed and indicated Patient 6 was admitted to the facility on May 30, 2025, for worsening psychosis (a mental health condition characterized by a loss of contact with reality), bizarre (acting strange or unusual) behaviors and not eating and sleeping.

A facility document titled, "PRACTITIONER ORDER SHEET," dated May 31, 2025, was reviewed. The document indicated, "...Latuda 40 mg PO q PM [referring to the time period after noon] with food...order given on 5/31/25 [May 31, 25] at 1445 [2:45 p.m.]..."

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated May 31, 2025, was reviewed. The document indicated, "...Latuda TAB 40 MG PO Q PM..."

There was no documented evidence a psychotropic medication consent for Latuda was obtained from Patient 6.

On September 3, 2025, at 11: 30 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation showing Patient 6 provided a medication consent which will include the explaination about Latuda. The CNO further stated the Latuda should have been included on the medication consent-psychotropic drug form since Patient 6 was prescribed the medication.

3. On September 3, 2025, at 9:40 a.m., a review of Patient 8's record was conducted with the CNO. A facility document titled, "INITIAL PSYCHIATRIC EVALUATION," dated July, 2 2025, was reviewed and indicated Patient 8 was admitted to the facility on July 2, 2025, for "relapsed on alcohol" and becoming intoxicated and depressed.

A facility document titled, "Medication Orders & [and] Prior Medication Reconciliation," dated July 2, 2025, was reviewed. The document indicated, "...Vistaril...anxiety...50 [fifty] mg PO q 4 [four] PRN [as needed...order given on 7/2/25 [July 2, 25] at 0933 [9:33 a.m.]..."

A facility document titled, "MEDICATION ADMINISTRATION RECORD," dated July 4, 2025, was reviewed. The document indicated, "...Ativan TAB 2 [two] MG PO Q4H...Trazadone TAB 100 MG PO QHS [every night]...Vistaril CAP [capsule] 50MG PO Q4H [every four hours]..."

There was no documented evidence a medication consent was obtained from Patient 8 for the psychotropic medications Trazadone, Vistaril, and Ativan.

On September 3, 2025, at 11:40 a.m., an interview was conducted with the CNO. The CNO stated there is no documentation showing Patient 8 received an explanation about Trazadone, Vistaril, and Ativan. The CNO further stated a psychotropic medication consent for Trazadone, Vistaril, and Ativan should have been obtained from Patient 8.

4. On September 3, 2025, at 9:50 a.m., a review of Patient 9's record was conducted with the CNO. A facility document titled, "INITIAL PSYCHIATRIC EVALUATION," dated July 30, 2025, was reviewed and indicated Patient 9 was admitted to the facility on July 30, 2025, for bizarre behavior. Patient 8 stated she heard voices telling her to hurt herself.

A facility document titled, "Medication Orders & Prior Medication Reconciliation," dated July 30, 2025, was reviewed. The document indicated, "...Vistaril...mood...50 mg PO PRN q4..."

A facility document titled, "PRN NOTES DOCUMENTATION REQUIRED," was reviewed. The document indicated, Patient 6 received Vistaril 50mg PO PRN on July 31, 2025, at 3:05 p.m., August 1, 2025, at 7:05 a.m., August 1, 2025, at 8:18 p.m., and August 2, 2025, at 9:02 p.m.

There was no documented evidence a psychotropic medication consent was obtained from Patient 9 for Vistaril.

On September 3, 2025, at 11:50 a.m., an interview was conducted with the CNO. The CNO stated there was no documentation showing Patient 9 received an explanation about Vistaril. The CNO further stated a psychotropic medication consent for Vistaril should have been obtained from Patient 9 .

On September 3, 2025, at 5 p.m., an interview was conducted with Psychiatrist (Psych, a physician who specialized in the diagnosis and treatment of mental illness) 1. Psych 1 stated the providers fill out the consent form indicating the prescribed medication and explain the psychotropic drugs to the patient before the patients receive their first dose of the medication. Psych 1 stated the nurse is responsible for obtaining the patient's signature prior to giving the first dose of medication to the patient. Psych 1 stated there must be a signed medication consent from the patient for the prescribed medication for the nurse to administer the psychotropic medication. Psych 1 further stated the medication consent should be obtained whenever a psychotropic medication is prescribed regardless if the patient receives the medication or not.

On September 4, 2025, at 1:59 p.m., an interview was conducted with the Registered Nurse (RN) 1. RN 1 stated if there is no consent for a medication, the nurse is supposed to pause and inform the charge nurse. RN 1 stated patients should not be given a psychotropic medication if there is no signed medication consent from the patient.

The facility P&P titled, "MEDICATION ADMINISTRATION AND RECORDS," dated July 2024, was reviewed. The P&P indicated, "...To establish procedures for timely, accurate, and safe administration of medication...All patient who are able to provide expressed and informed consent for psychotropic medications will do so prior to the initial dose...Documentation of expressed and informed consent will be verified by the Nursing Staff and recorded...the log is placed in the MAR [Medication Administration Record]. In addition, the MAR will reflect that consent has been documented..."