State Audit Finds Lack of Documentation Supporting Involuntary Drugging Of Patients
Patients in the state psychiatric facilities at Pueblo and Fort Logan were drugged against their will without sufficient documentation to justify the action, according to an audit report just released by the Colorado Office of the State Auditor.
The review of some patient files at the Colorado Mental Health Institutes at Pueblo and Fort Logan found that a number of them “lacked sufficient clinical documentation to substantiate that a psychiatric emergency existed warranting an emergency medication order.”
Additionally, the audit uncovered patients whose legal rights were violated when they were involuntarily drugged on a claimed emergency basis for more than 72 hours without the proper documentation of a second opinion and/or a written request for a court hearing, as required by state law.
The report further criticized the psychiatric institutions for lacking documentation to substantiate that the condition of patients warranted psychiatrists’ petitions to courts for, or their continued use of, court-ordered involuntary drugging.
Some patients’ current medications were not discontinued before they were involuntarily drugged on a claimed emergency basis, which resulted in patients having two sets of drugging orders in effect at the same time, with an increased risk to them of serious side effects.
Significantly Higher Error Rates in Administering Drugs
Average error rates in administering drugs in 2010 were significantly higher at the Institutes than the average rate for a comparable peer group of facilities. Specifically, Fort Logan averaged 4.50 errors per 100 drugging episodes, and Pueblo 4.93, as compared to an average of 2.71 in facilities in the peer group.
Further, there were cases in which the psychiatrist ordered two or three psychiatric drugs, including antipsychotics, on an as-needed basis for the same condition without sufficient documentation substantiating the need for multiple medications.
According to the report, several patients were found to have been put on the drug clozapine, an antipsychotic that has a potentially life-threatening side effect, without clear and sufficient documentation that less risky treatments had been tried first.
The psychiatric institutions also failed to do recommended medical follow-up on a number of patients to test for the dangerous side effects of certain antipsychotic drugs, such as the metabolic monitoring recommended by the American Diabetes Association for patients on certain antipsychotic drugs with well-known links to the onset of diabetes.
The facilities were found to have inconsistent guidelines and monitoring protocols for administering high-risk drugs, and in some cases, established guidelines were not followed.
The full audit report, “Psychiatric Medication Practices for Adult Civil Patients, Colorado Mental Health Institutes,” is posted in the June 2011 reports of the Office of the State Auditor.
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