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Based on record review, document review and interviews, the facility failed to:

1. Ensure that current standing prn [as needed] medication orders written by physicians were sufficiently prescriptive to direct nursing staff in their use for 4 of 8 active sample patients (C1, C2, C3 and C4) and 3 of 5 patients added to the sample for the evaluation of prn medications. (P1, P2 and NS3) As written, the standing prn orders allowed nursing staff to select one or more medications based on ill-defined parameters such as " severe mood swings " , " agitation " , " severe agitation " , " aggression " " agitation/anxiety " and " psychotic agitation. " Multiple prn orders with poorly defined parameters place nursing staff in the position of choosing between different prn medications or a combination of prn medications for the same indication without adequate physician guidance. Ambiguous physician orders, when carried out, also result in nurses practicing outside the scope of nursing practice, potentially negatively impacting on the health and well being of patients. (Refer to B125-I)

II. Ensure that prn medication orders written by physicians for " agitated " and " aggressive " behaviors for 3 of 8 active sample patients (C2, C3 and W2) and 2 of 5 non-sample patients added to evaluate prn medications (NS1 and P1) were identified as chemical restraint, Physicians prescribed prn medications for behavior control (agitated and aggressive behaviors) that were not part of these patients ' regular medication regimen, and did not identify these orders as chemical restraint orders. Nurses also administered the prn medications to sample patient C2 without following restraint procedures, including all documentations. These failures can result in harm to patients, and they violate patients ' rights to safe treatment in the least restrictive manner possible, (Refer to B125-II)

Based on record review, document review and interviews, the facility failed to:

I. Ensure that current standing prn [as needed] medication orders written by physicians were sufficiently prescriptive to direct nursing staff in their use for 4 of 8 active sample patients (C1, C2, C3 and C4) and 3 of 5 patients added to the sample for the evaluation of prn medications (P1, P2 and NS3). As written, the standing prn orders allowed nursing staff to administer one or more medications based on ill-defined parameters such as " severe mood swings " , " agitation " , " severe agitation " , " aggression " " agitation/anxiety " and " psychotic agitation. " Multiple prn orders with poorly defined parameters place nursing staff in the position of choosing between different prn medications or a combination of prn medications for the same indication without adequate physician guidance. Ambiguous physician orders, when carried out, also result in nurses practicing outside the scope of nursing practice, potentially negatively impacting on the health and well being of patients.

II. Ensure that prn medication orders written by physicians for " agitated " and " aggressive " behaviors for 3 of 8 active sample patients (C2, C3 and W2) and 2 of 5 non-sample patients added to evaluate prn medications (NS1 and P1) were correctly identified as chemical restraint, Physicians prescribed prn medications for behavior control (agitated and aggressive behaviors) that were not part of these patients ' regular medication regimen, and did not identify the orders as chemical restraint orders. Nurses also administered the prn medications to sample patient C2 without following restraint policy/procedures, including all documentations. These failures can result in harm to patients, and they violate patients ' rights to safe treatment in the least restrictive manner possible,
Findings Include:

I. Ambiguous medication orders

A. Specific Patient Findings

1. Patient C1 was admitted on 7/22/2010. The Psychiatric Evaluation dated 7/24/2010 revealed a diagnosis of " Phonological Disorder and Mild versus Moderate Mental Retardation. " The Physician ' s Order dated 1/04/2011 listed the following prn medications: " Chlorapromazine 100mg IM [intramuscular] q [every] 8h [hours] PRN for aggression " , " Chlorpromazine 200mg po [orally] q 8h PRN for aggression " , " Lorazepam 2mg po q 6h PRN for agitation " and " Lorazepam 2mg IM q 6h PRN for agitation. "

2. Patient C2 was admitted on 2/09/2011. The Psychiatric Evaluation dated 2/09/2011 revealed a diagnosis of " Posttraumatic Stress Disorder, Polysubstance Dependence, in remission in a controlled environment, Antisocial Personality Disorder, Mild Mental Retardation. " The Physician ' s Orders sheet dated 2/09/2011 listed the following prn medications: " Haldol 10mg po/IM q 6h PRN severe mood swing " , " Ativan 2mg po/IM q 6h PRN severe mood swing " , " Thorazine 200mg po q 8h PRN severe mood swing " and " Thorazine 100mg IM q 8 h PRN severe mood swing. "

Review of the Patient C2 ' s most recent One-Time Order and PRN Medication Record revealed that Patient C2 received Ativan 2mg/Haldol 10mg po for " Severe Mood Swing" on 2/11/2011, 2/12/2011 and 2/13/2011. Patient C2 also received Thorazine 200mg po for " Severe Mood Swing " on 2/10/2011.

3. Patient C3 was admitted on 2/04/2011. The Psychiatric Evaluation dated 2/05/2011 revealed a diagnosis of " Mood disorder, not otherwise specified, Rule out Bipolar Disorder, Rule out Posttraumatic Stress Disorder, Alcohol dependency, in remission. " The Physician ' s Orders sheet dated 2/07/2011 revealed the order, " Vistaril 50mg po or IM q 6 hours PRN severe agitation. " The Physician ' s Orders sheet dated 2/08/2011 listed the following additional PRN medications: " Ativan 1 mg po or IM q 6 [hours] prn for agitation related to mania/psychosis " and " Haldol 5mg po/IM q 6 [hours] prn for agitation related to mania/psychosis. "

4. Patient C4 was admitted on 2/01/2011. The Psychiatric Evaluation dated 2/ 02/2011 revealed a diagnosis of " Psychosis, NOS, Rule out Schizophrenia, Rule out Schizoaffective Disorder, bipolar type, Rule out Dementia. " The Physician Orders sheet dated 2/01/2011 listed the following PRN medications; " Haldol 10 mg po/IM q 6 hrs PRN for psychotic agitation " and " Ativan 2 mg po/IM q 6 hrs PRN for psychotic agitation. "

5. Patient P1 was admitted on 7/12/2010. The most recent Psychiatric Evaluation dated 11/7/2010 revealed a diagnosis of " Mood Disorder NOS, Mental Retardation, by history. " The most recent Physician Medication Order Renewal Form dated 2/08/2011 listed the following PRN medications: " Haloperidol 10mg po q 6H PRN Psychotic Agitation " , " Haloperidol 10ml Conc (Concentrate) po q 6H PRN Psychotic Agitation " , " Lorazepam 2mg po q 6H PRN Severe Agitation/Anxiety " and " Lorazepam 2mg IM q 6H PRN Severe Agitation/Anxiety. "

6. Patient P2 was admitted on 11/17/2010. The Psychiatric Evaluation dated 11/17/2010 revealed a diagnosis of " Mood Disorder, NOS, Mental Retardation by history. " The most recent Physician Medication Order Renewal Form dated 02/01/2011 listed the following PRN medications; " Chlorpromazine 100mg po q 4H PRN Agitation " , " Chlorpromazine 25mg IM q 4H PRN Agitation " , " Lorazepam 2mg po q 4H PRN Severe Agitation " and " Lorazepam 2mg IM q 4H PRN Severe Agitation. "

7. Patient NS3 was admitted on 1/19/2011. The Psychiatric Evaluation dated 1/19/2011 revealed a diagnosis of " Schizoaffective Disorder " . The Physician ' s Orders sheet dated 1/19/2011 listed the PRN medications, " Zyprexa Zydis 5mg po q 8 hrs PRN for Psychotic Agitation " and " Ativan 2mg po PRN Psychotic Agitation. "

B. Interviews

1. In an interview on 2/15/2011 at 10:50 a.m., LPN1 was asked how she would decide which prn medication to give Patient C2 for severe mood swings. (Haldol 10mg po/IM, Ativan 2mg po/IM and Thorazine 200mg po/100mg IM were all ordered prn for " severe mood swing " ) LPN1 stated that it would depend on the " severity of his mood and the type of behavior he was exhibiting. " LPN1 further stated that she and the other nurses would " ...get together and decide what is going to benefit him. " When asked if she would give two of the medications at the same time, LPN1 stated " I would give Haldol and Ativan together because they are compatible. " When asked if she would give Haldol and Thorazine at the same time LPN1 stated, " Not unless I called the doctor or pharmacist to find out if they were compatible. "

2. In an interview on 2/15/2011 at 2:30 p.m., when shown the multiple prn orders for Patient C2, the Medical Director stated, " I can ' t defend that. It (ordering multiple prns for the same purpose) puts nursing in a bad position. It ' s a la carte. "

3. In an interview on 2/15/2011 at 2:50 p.m., the Director of Nursing (DON) stated that making a decision about which prn medication to give a patient was " not within the nurse ' s scope of practice. " The DON voiced surprise that orders were written separately; stating, " I ' m used to orders being written together, like Haldol 10mg and Ativan 2mg, not written individually for the nurse to decide. "

II. Failure to identify prn medication as chemical restraint

A. Document Review
1. Arkansas State Hospital Policy and Procedure Manual Policy #ASH 05.01.07 revised May13, 2010 entitled " Use of Seclusion and Restraints, " defined Chemical Restraints as, " NOW medication orders for behavioral control are considered restraint. " Following the definition was a " Note " that stated, " PRN medications that are incorporated into the Treatment Plan are not considered restraints. "
2. In a letter to ASH [Arkansas State Hospital] medical staff dated 1/12/2011 the Medical Director stated, " If a clinically indicated prn is to be ordered on admission, if possible, place it on an Initial Treatment Plan. "
3. A document titled, " Adolescent Staff Meeting/Training " dated January 18, 2011 listed the following as an agenda item: " Anti-Psychotic prn Meds as Chemical Restraints. " The document stated, " Effective 1/18/11 if a patient ' s PRN Psychotropic medication is noted on the MTP [Master Treatment Plan] as part of his/her treatment plan this PRN when given will not be treated as a Chemical Restraint. "
4. In an undated training document titled, " Anatomy of a Treatment Plan, " the Clinical Director defined the relationship between PRNs and Chemical Restraint as: " For problems like elevated mood or anxiety attacks, PRN ' s can be included as an intervention on both the ITP [Initial Treatment Plan] and MTP [Master Treatment Plan]. We think this is also the case with violence or aggression ... [Medical Director] is doing some research to verify that. This is much simpler for documentation than having to document PRN ' s as chemical restraints. "
B. Specific Patient Findings:
1. Patient C2

Review of the Physician ' s Orders sheet for Patient C2 revealed an order dated 2/09/2011 for the following prn medications: " Haldol 10mg po/IM q 6h PRN severe mood swing " , " Ativan 2mg po/IM q 6h PRN severe mood swing " , " Thorazine 200mg po q 8h PRN severe mood swing " and " Thorazine 100mg IM q 8 hours PRN severe mood swing. "

Documentations on the patient ' s most recent " One-Time Order and PRN Medication Record " showed that Patient C2 received Ativan 2 mg/Haldol 10 mg po for " Severe Mood Swing" on 2/11/2011, 2/12/2011 and 2/13/2011. The patient also received Thorazine 200 mg po for " Severe Mood Swing " on 2/10/2011. Although Thorazine, Haldol and Ativan were not a part of the scheduled medications for Patient C2, the facility did not consider these orders to be a restraint order, nor was the medication administration considered a restraint

2. Patient C3

Review of the Physician ' s Orders for Patient C3 revealed an order dated 2/8/2011 for " Ativan 1 mg po/IM Q 6 [hours] for agitation related to mania/psychosis " and " Haldol 5 mg po/IM Q6 [hours] for agitation related to mania/psychosis. " Although Haldol and Ativan were not a part of the scheduled medications for Patient C3, the facility did not consider this order to be a prn restraint order.

3. Patient W2
Review of the Physician ' s Orders for Patient W2 revealed an order dated 1/26/2011 for " Haldol 10mg/Ativan 2mg po/IM q 6 [hours] PRN psychotic/impulsive agitation. " Although Haldol and Ativan were not a part of the scheduled medications for Patient W2, the facility did not consider this order to be a prn restraint order.
4. Patient NS1
Review of the Physician ' s Orders for Patient NS1 revealed an order dated 1/14/2011 for " Zyprexa Zydis 10mg po q 12 hour prn agitation/aggression. " Review of the patient ' s One-Time Order and PRN Medication Record revealed that Patient NS1 received Zyprexa Zydis 10mg po PRN for agitation on 1/29/2011, 1/31/2011, 2/04/2011, 2/06/2011, 2/08/2011 and 2/10/2011. Although Zyprexa Zydis was not a part of the scheduled medications for Patient NS1, the facility did not consider the order to be a prn restraint order.
5. Patient P1
Review of the most recent Physician Medication Order Renewal Form for Patient P1 dated 2/08/2011 revealed the following PRN medications: " Haloperidol [Haldol] 10mg po q 6H PRN Psychotic Agitation " , " Haloperidol 10 ml Conc [Concentrate] po q 6H PRN Psychotic Agitation " , " Lorazepam [(Ativan] 2mg po q 6H PRN Severe Agitation/Anxiety " and " Lorazepam 2mg IM q 6H PRN Severe Agitation/Anxiety. "
Review of the patient ' s " One-Time Order and PRN Medication Record " revealed that Patient P1 received Haldol 10mg/Ativan 2mg po for " Severe Agitation " on 2/05/2011 and Haldol 10mg/Ativan 2mg po for " Agitation " on 2/06/2011. Patient P1 received Haldol 10mg/Ativan 2mg IM for " Severe Agitation " on 2/03/2011 and Haldol 10mg/Ativan 2mg IM for " Increased Agitation " on 2/07/2011. On 2/11/2011 and 2/12/2011, Patient P1 received Haldol 10mg po for " Psychotic Agitation. " Although Haldol and Ativan were not a part of the scheduled medications for Patient P1, the facility did not consider the order to be a prn restraint order.
C. Interviews
1. In an interview on 2/14/11 at 1:30 pm, RN5 stated that her understanding of chemical restraints was any order that was a " NOW " order. However, RN5 also stated that if a medication was listed on the treatment plan, then administration of that medication for any reason would not be considered a chemical restraint.
2. In an interview on 2/14/2011 at 1:45 pm, RN2 stated that for a patient with a psychosis diagnosis, " A prn would not be a chemical restraint " but a patient with a diagnosis of depression could " ... not have a prn ordered " and if a depressed patient needed additional medication, " It would have to be a one-time order. " RN2 further stated that prns were not chemical restraints because, " I have an order to back me up. "
3. In an interview on 2/14/11 at 2:15 pm, RN4 stated that her understanding of the hospital ' s current chemical restraint policy was as long as a prn medication was listed on the MTP (Master Treatment Plan), administration of the medication was not considered a chemical restraint. She further stated that she disagreed with this policy and that it was not in keeping with her experience in other local hospitals in which she was currently also working, but she would follow what the hospital policy stated.
4. In an interview on 2/15/2011 at 10:45 a.m., RN3 stated that giving Haldol, Thorazine and Ativan prn to Patient C2 was not considered a chemical restraint because, " It is on the Master Treatment Plan. "
5. In an interview on 2/15/11 at 11:30 a.m., RN5 reviewed the usage of prn Zydis for patient NS1. RN5 noted that she believed the meds should have been administered as NOW medications which would require a Chemical Restraint protocol.
6. A meeting was held on 2/15/11 at 2:45 p.m. with the Medical Director, Clinical Director and the CEO to discuss the facility concept of chemical restraints. In this meeting, the Medical Director stated that the current policy was designed to allow staff to have some latitude in making decisions about patients ' pharmacologic care. The Medical Director acknowledged that there were instances when meds were not being listed on the treatment plans, and times when med administration should have been considered chemical restraint.

Based on record review, document review and interviews, the Medical Director failed to:

1. Ensure that current standing prn [as needed] medication orders written by physicians were sufficiently prescriptive to direct nursing staff in their use for 4 of 8 active sample patients (C1, C2, C3 and C4) and 3 of 5 patients added to the sample for the evaluation of prn medication use. (P1, P2 and NS3). As written, standing prn orders allowed nursing staff to administer one or more medications based on ill-defined parameters such as " severe mood swings " , " agitation " , " severe agitation " , " aggression " " agitation/anxiety " and " psychotic agitation. " Multiple prn orders with poorly defined parameters place nursing staff in the position of choosing between different prn medications or a combination of prn medications for the same indication without adequate physician guidance. Ambiguous physician orders, when carried out, result in nurses practicing outside the scope of nursing practice, potentially negatively impacting on the health and well being of patients. (Refer to B125-I)

II. Ensure that prn medication orders written by physicians for " agitated " and " aggressive " behaviors for 3 of 8 active sample patients (C2, C3 and W2) and 2 of 5 non-sample patients added to evaluate prn medications (NS1 and P1) were correctly identified as chemical restraint, Physicians prescribed prn medications for behavior control (agitated and aggressive behaviors) that were not part of these patients ' regular medication regimen, and did not identify the orders as chemical restraint orders. Nurses also administered the prn medications to sample patient C2 without following restraint policy/procedures, including all documentations. These failures can result in harm to patients, and they violate patients ' rights to safe treatment in the least restrictive manner possible. (Refer to B125-II)

Based on record review, document review and interviews, the Director of Nursing failed to monitor nursing practice to:

I. Ensure that nurses did not carry out physician ' s medication orders that were not sufficiently prescriptive to direct nursing staff in their use for 1 of 8 active sample patients (C2). As written, the standing prn orders allowed nursing staff to administer one or more medications to the patient based on ill-defined parameters (nurses to administer multiple meds " po " or " IM " for " mood swings " or " severe mood swing " ). Carrying out ambiguous physician orders results in nurses practicing outside the scope of nursing practice, potentially negatively impacting on the health and well being of patients.

II. Ensure that nurses identified prn medication orders for behavior control as chemical restraints and completed all required restraint procedures and documentations for 1 of 8 active sample patients (C2). Nurses administered the prn medications to this patient for behavior control without following proper restraint policy/procedures, including all documentations. This failure can result in harm to patients, and they violate patients ' rights to safe treatment in the least restrictive manner possible.
Findings include:
I. Failure to recognize and decline to administer ambiguous prn medication orders
A. Record Review
Patient C2 was admitted on 2/09/2011. The Psychiatric Evaluation dated 2/09/2011 revealed a diagnosis of " Posttraumatic Stress Disorder, Polysubstance Dependence, in remission in a controlled environment, Antisocial Personality Disorder, Mild Mental Retardation. " The Physician ' s Orders sheet dated 2/09/2011 listed the following prn medications: " Haldol 10mg po/IM q 6h PRN severe mood swing " , " Ativan 2mg po/IM q 6h PRN severe mood swing " , " Thorazine 200mg po q 8h PRN severe mood swing " and " Thorazine 100mg IM q 8 h PRN severe mood swing. "
Review of the Patient C2 ' s most recent One-Time Order and PRN Medication Record revealed that Patient C2 received Ativan 2mg/Haldol 10mg po for " Severe Mood Swing" on 2/11/2011, 2/12/2011 and 2/13/2011. Patient C2 also received Thorazine 200mg po for " Severe Mood Swing " on 2/10/2011.

B. Interviews

1. In an interview on 2/15/2011 at 10:50 a.m., LPN1 was asked how she would decide which prn medication to give Patient C2 for severe mood swings. (Haldol 10mg po/IM, Ativan 2mg po/IM and Thorazine 200mg po/100mg IM were all ordered prn for " severe mood swing " ) LPN1 stated that it would depend on the " severity of his mood and the type of behavior he was exhibiting. " LPN1 further stated that she and the other nurses would " ...get together and decide what is going to benefit him. " When asked if she would give two of the medications at the same time, LPN1 stated " I would give Haldol and Ativan together because they are compatible. " When asked if she would give Haldol and Thorazine at the same time LPN1 stated, " Not unless I called the doctor or pharmacist to find out if they were compatible. "

2. In an interview on 2/15/2011 at 2:30 p.m., when shown the multiple prn orders for Patient C2, the Medical Director stated, " I can ' t defend that. It (ordering multiple prns for the same purpose) puts nursing in a bad position. It ' s a la carte. "

3. In an interview on 2/15/2011 at 2:50 p.m., the Director of Nursing (DON) stated that making a decision about which prn medication to give a patient was " not within the nurse ' s scope of practice. " The DON voiced surprise that orders were written separately; stating, " I ' m used to orders being written together, like Haldol 10mg and Ativan 2mg, not written individually for the nurse to decide. "

II. Failure to identify prn medication orders for behavior control as chemical restraints and follow S/R procedures/documentations
A. Record Review
Patient C2 was admitted on 2/09/2011. The Psychiatric Evaluation dated 2/09/2011 revealed a diagnosis of " Posttraumatic Stress Disorder, Polysubstance Dependence, in remission in a controlled environment, Antisocial Personality Disorder, Mild Mental Retardation. " The Physician ' s Orders sheet dated 2/09/2011 listed the following prn medications: " Haldol 10mg po/IM q 6h PRN severe mood swing " , " Ativan 2mg po/IM q 6h PRN severe mood swing " , " Thorazine 200mg po q 8h PRN severe mood swing " and " Thorazine 100mg IM q 8 h PRN severe mood swing. "
Review of the Patient C2 ' s most recent One-Time Order and PRN Medication Record revealed that Patient C2 received Ativan 2mg/Haldol 10mg po for " Severe Mood Swing" on 2/11/2011, 2/12/2011 and 2/13/2011. Patient C2 also received Thorazine 200mg po for " Severe Mood Swing " on 2/10/2011. The medications were not recognized as chemical restraint, and there was no evidence that proper restraint procedures were followed, including required documentations.

B. Document Review
1. Arkansas State Hospital Policy and Procedure Manual Policy #ASH 05.01.07 revised May13, 2010 entitled " Use of Seclusion and Restraints, " defined Chemical Restraints as, " NOW medication orders for behavioral control are considered restraint. " Following the definition was a " Note " that stated, " PRN medications that are incorporated into the Treatment Plan are not considered restraints. "
2. In a letter to ASH [Arkansas State Hospital] medical staff dated 1/12/2011 the Medical Director stated, " If a clinically indicated prn is to be ordered on admission, if possible, place it on an Initial Treatment Plan. "
3. A document titled, " Adolescent Staff Meeting/Training " dated January 18, 2011 listed the following as an agenda item: " Anti-Psychotic prn Meds as Chemical Restraints. " The document stated, " Effective 1/18/11 if a patient ' s PRN Psychotropic medication is noted on the MTP [Master Treatment Plan] as part of his/her treatment plan this PRN when given will not be treated as a Chemical Restraint. "
4. In an undated training document titled, " Anatomy of a Treatment Plan, " the Clinical Director defined the relationship between PRNs and Chemical Restraint as: " For problems like elevated mood or anxiety attacks, PRN ' s can be included as an intervention on both the ITP [Initial Treatment Plan] and MTP [Master Treatment Plan]. We think this is also the case with violence or aggression ... [Medical Director] is doing some research to verify that. This is much simpler for documentation than having to document PRN ' s as chemical restraints. "
C. Interviews
1. In an interview on 2/14/11 at 1:30 pm, RN5 stated that her understanding of chemical restraints was any order that was a " NOW " order. However, RN5 also stated that if a medication was listed on the treatment plan, then administration of that medication for any reason would not be considered a chemical restraint.
2. In an interview on 2/14/2011 at 1:45 pm, RN2 stated that for a patient with a psychosis diagnosis, " A prn would not be a chemical restraint " but a patient with a diagnosis of depression could " ... not have a prn ordered " and if a depressed patient needed additional medication, " It would have to be a one-time order. " RN2 further stated that prns were not chemical restraints because, " I have an order to back me up. "
3. In an interview on 2/14/11 at 2:15 pm, RN4 stated that her understanding of the hospital ' s current chemical restraint policy was as long as a prn medication was listed on the MTP (Master Treatment Plan), administration of the medication was not considered a chemical restraint. She further stated that she disagreed with this policy and that it was not in keeping with her experience in other local hospitals in which she was currently also working, but she would follow what the hospital policy stated.
4. In an interview on 2/15/2011 at 10:45 a.m., RN3 stated that giving Haldol, Thorazine and Ativan prn to Patient C2 was not considered a chemical restraint because, " It is on the Master Treatment Plan. "
5. In an interview on 2/15/11 at 11:30 a.m., RN5 reviewed the usage of prn Zydis for patient NS1. RN5 noted that she believed the meds should have been administered as NOW medications which would require a Chemical Restraint protocol.
6. A meeting was held on 2/15/11 at 2:45 p.m. with the Medical Director, Clinical Director and the CEO to discuss the facility concept of chemical restraints. In this meeting, the Medical Director stated that the current policy was designed to allow staff to have some latitude in making decisions about patients ' pharmacologic care. The Medical Director acknowledged that there were instances when meds were not being listed on the treatment plans, and times when med administration should have been considered chemical restraint.