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Based on record review and interview, the hospital failed to ensure that patients or his or her representative has the right to make informed decisions regarding care as evidenced by failing to obtain consent for psychoactive medications for 3 of 3 sampled adolescent patients (Patient #1, 2, 3).
Findings:

Review of the hospital policy, titled Use of Psychotropic Medication Without Patient Consent (dated 03/21/2028), revealed in part that the hospital permits the administration of psychotropic meds without patient consent under one of the following circumstances:
The patient is experiencing a psychiatric emergency and medication must be administered to prevent imminent harm OR
The treating physician has made contact or has attempted to contact the patient's primary care physician or a prior treating physician AND
A second physician documents clinical justification for administration of psychotropic medication, without the patients consent after making an appropriate assessment OR
The second physician that was the patient's treating physician prior to this hospitalization, consults with the treating psychiatrist and indicates support of medicating the patient without his/her consent. In this case, the treating psychiatrist shall document the date, time, and content of the verbal consultation.

1. Review of the medical record for Patient #1, who was 14 years old, revealed an admit date of 08/24/2024 with diagnoses including major depressive disorder and generalized anxiety disorder. The patient was admitted on a PEC, and the patient's mother signed a formal voluntary admission consent on 08/26/2024.

Review of physician orders dated 08/25/2024 revealed an order for Zoloft (psychoactive medication used for depression) 25mg every night for two nights, then 50mg every night. Review of the patient's MAR revealed the patient received the Zoloft on 08/26/2024 and 08/27/2024.

Further review of the medical record revealed there was no consent obtained prior to administering the psychoactive medication, Zoloft, to the patient. There was also no documented evidence that two physicians were involved in the approval of administering the medication, per hospital policy.

On 09/17/2024 at 10:00 a.m., interview with S1CEO confirmed that the hospital policy states to obtain consent from the parents prior to administering psychoactive medication to the child/adolescent patients of the hospital. S1CEO confirmed consent was not obtained prior to administering psychoactive medication to Patient #1.

2. Review of the medical record for Patient #2, who was 16 years old, revealed an admission date of 08/25/2024 with a diagnosis of major depression.

Review of the following physician orders revealed orders for psychoactive medication:
08/27/2024- Methylphenidate ER 27mg daily
09/02/2024- Risperdal 1mg four times daily
09/02/2024- Zoloft 100mg every night
09/06/2024- Methylphenidate ER 36mg daily
09/07/2024- Methylphenidate 5mg daily
09/07/2024- Prazosin 1mg every night

Further review of the medical record revealed the patient was administered the above psychoactive medications without first getting consent by the patient's parent/guardian or by getting the approval of two physicians (per policy).

On 09/16/2024 at 2:45 p.m., S2QA reviewed the patient's medical record with the surveyor and confirmed there was no documented evidence that consent was obtained prior to administering the above psychoactive medications to the patient. S2QA further confirmed there was no documented evidence that two physicians approved the administration of the medication. S2QA confirmed that psychoactive medications should not be administered prior to obtaining consent.

3. Review of the medical record for Patient #3, who was 9 years old, revealed an admission date of 09/06/2024 with a diagnosis of disruptive mood dysregulation disorder.

Review of the following physician orders revealed orders for psychoactive medication:
09/09/2024- Zoloft 50mg daily
09/09/2024- Abilify 10mg daily

Further review of the medical record revealed the patient was administered the above psychoactive medications without first getting consent by the patient's parent/guardian or by getting the approval of two physicians (per policy).

On 09/16/2024 at 2:20 p.m., S2QA reviewed the patient's medical record with the surveyor and confirmed there was no documented evidence that consent was obtained prior to administering the above psychoactive medications to the patient. S2QA further confirmed there was no documented evidence that two physicians approved the administration of the medication.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an incident with an adolescent patient involving failure to obtain consent for psychoactive medications.
Findings:

Review of a written grievance, dated 08/28/2024, completed by the parents of Patient #1 revealed before meds were administered, parents explicitly demanded that the child was not given meds without parental consent. We were told that consent was absolutely needed before meds would be given. Upon visit on 8/28/24, we were informed by our daughter that she was given two separate doses of a green pill.

The hospital's written response to the grievance, dated 08/28/2024, and sent to the parents of Patient #1 was reviewed. The response revealed in part that the corporate team was reviewing current policy on administering medication to minors and that staff would undergo education now and annually on proper handoff communication and obtaining medication consents.

Review of the LDH Abuse/Neglect initial report dated 08/29/2024 revealed that Patient #1's parents visited on 08/24/2024 and informed staff they did not want to start the patient on medications. Parents made another visit on 08/28/2024 and the patient reported she had started a new medication. The report further stated that the chart was audited and Zoloft (psychoactive medication) was administered to the patient on 08/27/2024 and 08/28/2024. There was no consent for the medication on the chart or any documentation from conversation with the mother about not wanting her daughter to be on any medications. The report further stated that the investigation showed a lack of communication in handoff between nurses concerning new medication orders.

On 09/17/2024 at 10:00 a.m., interview with S1CEO revealed that since this incident with Patient #1, the hospital is reviewing policies related to obtaining consent for psychoactive medication. S1CEO confirmed the current policy states to obtain consent prior to administering psychoactive medications to patients. S1CEO confirmed consent was not obtained prior to administering Zoloft to Patient #1.

Review of the medical record for currently admitted Patient #2 revealed the patient had been administered the following psychoactive medications without documentation of consent from the parent/responsible party or the approval of two physicians (per policy):
Methylphenidate ER 27mg daily (ordered 08/27/2024)
Risperdal 1mg four times daily (ordered 09/02/2024)
Zoloft 100mg every night (ordered 09/02/2024)
Methylphenidate ER 36mg daily (ordered 09/06/2024)
Methylphenidate 5mg daily (ordered 09/07/2024)
Prazosin 1mg every night (ordered 09/07/2024)

Review of the medical record for currently admitted Patient #3 revealed the patient had been administered the following psychoactive medications without documentation of consent from the parent/responsible party or the approval of two physicians (per policy):
Zoloft 50mg daily (ordered 09/09/2024)
Abilify 10mg daily (ordered 09/09/2024)

On 09/17/2024 at 10:30 a.m., interview with S2QA revealed that after identifying the problem with communication and the failure to obtain consent for the psychoactive medication involving Patient #1 on 08/28/2024, all staff were inserviced on proper communication and obtaining consents for psychoactive medications.

Review of the sign in sheets for the inservice training on proper communication and obtaining consents revealed only 7 of 32 current staff had been inserviced. On 09/17/2024 at 11:00 a.m., interview with S2QA revealed that she had not gotten to all staff yet, although it had been three weeks since the incident and identification of the problem.

On 09/17/2024 at 11:20 a.m., when S2QA was asked if there had been any QA/monitoring put into place after the incident with Patient #1 to ensure consents are being obtained, she stated no.

On 09/17/2024 at 11:25 a.m., interview with S1CEO confirmed that monitoring should have been put in place to ensure consents were being obtained for psychoactive medications. Informed S1CEO that upon review of current patients (Patient #2 and Patient #3) medical records, consents for psychoactive medications were still not being obtained. S1CEO stated the system was still broken.