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Based on chart reviews, interviews, and policy and procedures reviews the facility failed to follow their own policy and procedure administering chemical restraints. The facility failed to ensure the documentation of nursing interventions were given before a chemical restraint, and the staff inability to identify when a drug or medication is considered a chemical restraint in 1(#1) of 6 (#1-6) charts reviewed.

Review of the nurse's note in patient #1's chart on 6/3/15 at 8:45 PM stated, "Pt returned to unit agitated and yelling at a female peer, requested to speak with nurse. Pt reported Suicidal Ideation (SI) with plan to choke self, cut, or take pills. Pt unable to contract for safety. Pt placed on 1:1(one staff member to one patient) while awake for safety per MD order. Will continue to monitor. Pt reported that she had sex with her roommate but does not remember when. Pt unable to give many details. Pt room changed and blocked to other roommates. Placed on sexual perpetrator precautions. Pt tried to choke self with hands, pt. was stating, "I just want to die." Staff notified MD received order for Zyprexa Zydis 10 mg x 1 dose now. Pt refused to take medication. Notified MD, received order for Ativan 2 mg IM, Haldol 5 mg IM, and Benadryl 50 mg IM 1 x now. Pt tolerated injections well. Pt is being monitored on 1:1 will continue to monitor closely."

There was no documentation found if the patient agreed to take the IM injections or if a hold was required. There was no documentation of a chemical restraint administered. There was no nursing interventions documented before the medication was administered.

Review of the policy and procedure Restraint/Seclusion stated, "Definitions; Chemical Restraint - The use of a chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individuals medical or psychiatric condition. Prohibited and Restricted Practices;

a. The following practices are prohibited:

ii. A chemical restraint. "

There was no further documentation found of chemical restraint administration in the facility's policy and procedure.

During an interview with RN Risk Manager on 7/30/2015 stated, "We don't do chemical restraints here. "RN Risk Manager and Administrator were shown the behavioral chemical restraint given to patient #1 they both confirmed a chemical restraint was administered. RN Risk Manager reported that it has been confusing to them and she was under the impression they were not considered chemical restraints.

An interview with the Administrator on 7/30/2015 reported she had been in the facility for a month in the role of administrator and she was already working on the chemical restraint policy. The Administrator reported she would address the staff on 7/30/2015 concerning chemical restraints and get teaching out to the staff as soon as possible.

Based on chart reviews and staff interviews the facility failed to modify the treatment care plan for a chemical restraint intervention in 1 (#1) out of 6 (#1-6) charts reviewed.

Review of patient #1's chart revealed there was no documentation found in patient #1's treatment care plan addressing the administration of chemical restraint intervention, administration, or assessment/evaluation of patient #1 during this time frame.

An interview with staff #11(RN) and staff #2 on 7/30/2015 confirmed the above findings. Staff #11 reported the treatment plan forms were just changed last month and is new to everyone. Staff #11 reported it was not an excuse but the other staff members were also having difficulty using the forms.

An interview with Staff #2 on 7/30/2015 reported the last Director of Psychiatric Nursing (DPN) implemented the treatment plan change and then resigned from the facility. Staff #2 reported that is also in the Performance Improvement (PI) to address this issue and decide if this is going to be effective for the facility and what teaching issues are needed.