HospitalInspections.org

Based on record review and interview, the facility failed to ensure signed informed consents for Psychoactive drugs/medications (used to treat mood, thoughts, behavior or perception) was obtained for 1 of 10 patients (Patient #1) in a sample of 10 records reviewed.

Findings include:

A review of facility policy, titled "Medication Administration-Guidelines", dated 01/13/2022, revealed: "...Medications are only given with a Physician/APRN (advanced practice nurse) order...A signed consent for a new psychoactive drug is required, except given in an emergency. Each new psychoactive drug must have its own consent form. Consent must be obtained prior to giving medication, except if given in an emergency..."

Patient (Pt.) #1 was a 16-year-old male voluntarily admitted on 09/25/2023 and discharged on 10/09/2023, his Mom was his legal guardian to give/sign consents throughout his hospitalization.

A review of Pt. #1's "Medication Administration Record", dated 09/25/2023 at 11:06 PM - 10/09/2023 at 12:28 PM, revealed a new Psychoactive medication, Wellbutrin XL 150 mg oral once a day for depression, was ordered on 10/05/2023 at 1:05 AM by Psychiatrist L - with first dose administered on 10/05/2023 at 9:00 AM.

During an interview on 11/29/2023 at 2:23 PM, Director of Medical Records J confirmed that all medication consents for Pt. #1 were printed; there was no medication consent for Wellbutrin XL 150 mg daily prior to medication administration - per facility policy.