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Based on record review and interview the facility failed to ensure that medication dosages were appropriate for the intervention and within standard treatment dosing for 1 (P (patient) 11) of 10 (P11-P20) patients reviewed for restraint use. The facility failed to follow policies in place related to ordering chemical restraints and failed to ensure staff was trained on the policy. This failed practice can lead to poor outcomes for the patient related to medication side effects.

The findings are:

A. Record review of facility policy titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" dated 12/2022 on page 2 under, "Definitions" it states, "Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute episodic behavior, [sudden and short lived outburst of aggression, agitation, etc.] with the intent to restrict the patient's functioning or movement and/or to bring about sedation. Medication/chemical restraint occurs when a patient is given a medication or combination of medications to control the patient's acute episodic behavior or restrict the patient's freedom of movement and/or which is not the standard treatment or dosage prescribed for the patient's condition. Whether an order for a medication is ONE TIME, PRN [as needed], or STAT [immediately] does not determine whether the use of that medication is considered a restraint; if the specific purpose of administering that medication, at that dose, via that route, and at that time is to impact acute episodic behavior, it qualifies as a chemical restraint."

B. Record review of P11's "Seclusion/Restraint Order" dated 08/13/2023 at 9:15 PM revealed that the "Type of Intervention" was "Physical Restraint" under "Less Restrictive Interventions to prevent use" it is written "Benadryl [medication given for allergies but used in psychiatry to help with side effects and/or sedative effects] 50 mg (milligrams), IM [intramuscular, injection into the muscle] 1X [1 time]" and "Haldol [medication given for agitation] 5 mg IM 1X."

C. Record review of P11's "Medication Administration Record" revealed that on 08/13/23 at 11:42 PM the patient received Haldol 5 mg oral "STAT for Agitation" along with Benadryl 100 mg oral "STAT for Agitation".

D. Record review of P11's "Medication Administration Record" revealed that on 08/14/23 at 12:06 AM the patient received Haldol 5 mg injection "Now for Agitation" along with Benadryl 50 mg injection "Now for Agitation".

E. Record review of P11's "Daily Nurse Progress Note" dated 08/14/2023 under "2300-0700 [11:00 PM - 7:00 AM] Sleep/Behaviors Note" stated "Restrained @ [at] 2115 [9:15 PM] for 30 min [minutes] w/ [with] IM 50 [mg] Benadryl/5 [mg] Haldol for pushing tech. . ."

F. Record review of P11's medical record does not reveal that a chemical restraint was ordered or documented on 08/13/2023 at 9:15 PM per policy.

G. During an interview on 09/07/2023 at 10:45 AM with S19, Registered Nurse (RN) it was asked if Benadryl is given to calm a patient down during an acute episode of agitation or aggression is an order for chemical restraint obtained. It was answered, "From my understanding a chemical restraint is if the child falls asleep right away. I would get the order for the restraint if the child falls asleep [after administration of the medication]."

H. During an interview on 09/07/2023 at 10:58 AM with S16, Medical Doctor (MD) confirmed that an order needs to be placed if a chemical restraint is used. It was asked if a medication is given to calm a child who is acting out in an aggressive or disruptive manner is that medication considered a restraint. It was explained that it would only be considered a restraint if the medication sedates the patient.

I. During an interview on 09/07/2023 at 11:15 AM with S3, Chief Nursing Officer it was asked when does medications become considered a chemical restraint. It was answered, "If it is not the usual dose or if we specifically give a medication that prevents a patient from returning to normal programming [term utilized for daily activities like group, therapy, etc. while in treatment at the hospital]."

Based on record review and interview the facility failed to ensure that the least restrictive intervention was used before moving on to the next intervention for 1 (P [patient]11) of 10 (P11-P20) patients reviewed for restraint use. This failed practice can lead to poor outcomes for the patient related to medication side effects.

The findings are:

A. Record review of facility policy titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" dated 12/2022 on page 4 under "Procedure" it states, "Use of Less-Restrictive Measures: The RN [registered nurse] and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/restraint, including: 1. Redirecting the patient's focus 2. Employing verbal de-escalation 3. Separating patient from group or community 4. Engaging the patient in 1:1 (one to one) activity to promote safe expression of feelings 5. Offering the use of the quiet room to decrease stimuli [something that can cause an increase in energy or excitement] and regain control 6. Offering food and drinks 7. Administering medication as ordered by the physician to help the patient more effectively function in his/her environment 8. Documents the alternatives attempted or the rationale for not using alternatives as well as the patient's response to those measures."

B. Refer to tag A-0160 finding B. - D.

C. Record review of P11's "Post Intervention Face to Face Evaluation" dated 08/13/2023 at 10:00 PM it is documented under, "Assessment of Immediate Situation" that patient is "sitting in room." The "Patient's Response to the Intervention" is documented as "Calmer".

D. During an interview on 08/31/2023 at 12:45 PM with S(staff) 3, Chief Nursing Officer it was asked how long should staff wait after administering oral medications for agitation to be effective. It was explained at least 30 minutes to an hour.

E. During an interview on 08/31/2023 at 12:05 PM with S16, Medical Doctor it was asked if it would be appropriate to give 5 mg of Haldol and 50 mg of Benadryl injection less than 30 minutes after administering oral doses of the same medications. It was answered "Generally not, but it depends on what is going on, there are situations that fall outside the normal."