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Based on review of medical records, policy, and interview, the facility failed to properly classify the medications given as Chemical Restraints to 2 patients (Patient #2 and Patient #21) of 3 patients medical records reviewed. Failure to properly classify medications as Chemical Restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility with the potential to result in harm to the patients.

Findings were as follows:

Patient #2

On 5-20-25, a list of psychoactive medications commonly used during psychiatric emergencies was reviewed. Patient #2 was identifies as having an order for Haldol (an antipsychotic medication) on 2/13/2025. Review of the Patient Safety Event Report showed that the medication was given on 2-13-25 for, "Patient acting out, threatening, yelling etc. Physical restraint and medication used."

On the afternoon of 5-20-25 at 1:30 PM at the Behavioral Health Center, patient charts were reviewed with Staff #4 and Staff #5. Staff #23 joined in the review at the end of the review.

Patient #2's chart contained a restraint package dated 2-14-25. The package indicated the patient received a physical hold (time of intervention was documented as 4:55 PM). The reason listed was the patient was an "imminent danger to self". The patient behaviors described were, "Pt running into door & falling, internally preoccupied unable to be verbally redirected." Prior to initiating a restraint, less restrictive interventions should be attempted and documented on the restraint form. Less restrictive interventions listed included non-emergency medication ordered. The form indicated the patient was given Haldol, 5 milligrams, injected with a syringe and needle into a muscle once for agitation and Cogentin, 2 milligrams injected with a syringe and needle into a muscle once for side effects possible from receiving Haldol. Review of the Medication Administration Record showed it was administered at 4:55 PM, the same time as the physical restraint.

Patient #21

Review of Patient #21's chart revealed the patient had restraint packages completed on 3-3-25, 3-4-25 and 3-5-25. Each one identified a physical restraint used because the patient was identified to be an imminent risk to self or others. Each one identified that a psychoactive medication was administered as a "non-emergency medication" as a less restrictive intervention prior to initiating a restraint. The Medication Administration Record showed that all were given after the initiation of a physical restraint and not prior to the restraint in an attempt to use less restrictive measures.

When questioned as to why these medications for Patient #2 and Patient #21 were not documented as an Emergency Psychoactive Medication (Chemical Restraint) administration, Staff #4 first explained that it had been given prior to the hold. When the time discrepancy was pointed out, Staff #4, Staff #5, and Staff #23 explained that if the medication was a standard dose (not higher than a normal dose) and the patient accepted it willingly, it was not classified as an Emergency Psychoactive Medication (Chemical Restraint) administration by the hospital. When asked why it wasn't given in the pill form (since pill form is the standard treatment) and instead was given in shot form (injected with a syringe and needle into a muscle), they agreed there was a need for the rapid onset of medication to control the patient behavior. Pill form would take longer to have an affect on behaviors, allowing patients to remain a threat to themselves and others. When asked what would have been done if the patients had refused to accept the shot willingly, Staff #4, Staff #5, and Staff #21 agreed that the patients' behaviors would have required administration of medication without patient consent to protect the patients and others.