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Based on review of the patient charts, review of policy and procedure, and interviews the facility failed to follow its own policy and procedures, and failed to have a face to face assessment performed in 1(#3) out of 5(#1-5) charts reviewed.

Review of patient #3's Multi-Disciplinary Note dated 12/19/15 at 7:15PM revealed patient #3 was yelling, cursing, and disturbing other patient. The nurse made a call to the psychiatrist and received a new order. Nurse received an order for Ativan 1 mg by mouth for anxiety and Depakote ER 500mg now and then daily. Patient #3 "refused" by mouth medications.

Review of the verbal physician order dated 12/19/15 at 7:25PM stated, "Haldol 10mg, Ativan 2mg and Benadryl 25mg IM now x1 dose for acute psychosis and refusal of meds."

Review of the Multi-Disciplinary Note dated 12/19/15 at 8:00PM the Licensed Vocational Nurse (LVN) documented, "Inject of Haldol 10mg given in left deltoid and Ativan 2 mg and Benadryl 25mg given in right deltoid IM. Pt tolerated well." The RN documented, " Pt escorted to quiet room and administered PRN Im shot of Haldol, Ativan, Benadryl. There was no documentation that patient #3 accepted the injections or if the patient was held.

Review of the chart revealed there was a Doctors Order Sheet for Seclusion/Restraints found dated 12/19/2015 at 8:00PM by the RN. The order stated to place patient in chemical restraint. Under "List Specific Interventions Attempted and Response in Progress Notes" was found blank. The psychiatrist signed the order on 12/20/15 at 12:20PM. Review of the Multi-Disciplinary Note dated 12/19/15 at 8:00PM revealed the DPN was at the facility for a face to face evaluation but no One Hour Face to Face Evaluation Form was found.

Review of the facility's policy and procedure, "Emergency Restraint and Seclusion" page 21 of 22 stated, "Permitted Practices Not to Be Considered Restraint/Seclusion: the following are permitted under Texas law not to be considered a restraint/ seclusion or a prohibited practice;
Intramuscular psychoactive medication administrative/brief physical hold."

Based on review of nursing schedules and interviews the facility failed to have a Registered Nurse (RN) available at all times to provide patient care.

Review of the nursing schedules revealed an RN was not available to relieve the RN performing patient care during dinner breaks.

An interview with staff #1 and #2 on 1/8/16 revealed there had not been an RN to relieve on nights, weekends, and on holidays but there was always an RN to relieve on days. Staff #2 confirmed there was no proof of that on the schedule. The relief RN had always been a salaried RN and was not put on the schedule.

Staff #1 and #2 corrected the staffing schedule before the surveyor left the facility on 1/8/16. An RN was scheduled to relieve the RN for dinner breaks on all shifts. Staff #1 confirmed there would always be sufficient staff to cover the RN as well as the other required staff.