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Based on review of clinical records and interview it was determined the Facility failed to assure chemical restraints were not ordered PRN (as needed) in 3 (#15, #17 and #18) of 5 (#15, #16, #17, #18 and #19) medical records reviewed for restraint use. Failure to assure chemical restraints were not ordered PRN did not assure Patients behavior was managed by physician order and not at the discretion or convenience of staff. The failed practice was likely to affect all patients admitted to the Facility that needed restraints. Example of the findings follow:

A. Patient #15 was admitted 12-18-16 to the Emergency Room. Review of the Orders written by Physician #1 for Patient #15 on 12-18-16 revealed: Medication haloperidol (HALDOL) 5mg/mL injection (IM) Ordered Dose: 10 mg Route: IntraMUSCular Frequency: Every 6 hours PRN (as needed) for agitation, mod-severe agitation, aggression, severe or threatening behavior. If refuses PO (by mouth).

B. Patient #17 was admitted 12-30-16 to the Emergency Room. Review of the Orders written by Physician #2 for Patient #17 on 12-30-17 revealed: Medication haloperidol (HALDOL) 1mg tablet Ordered Dose: 1mg Route: Oral Frequency: Every 6 hours PRN for agitation, as needed Moderate to aevere psychotic agitation.

C. Patient #18 was admitted 12-20-16 to the Emergency Room. Review of the Orders written by Physician #1 for Patient #18 on 12-20-16 revealed Medication haloperidol (HALDOL) 5 mg/mL injection (IM) Ordered Dose: 5mg Route: IntraMUSCular Frequency: Every 6 hours PRN for mod-severe agitation, aggression, severe or threatening behavior. If refuses Prolixin PO.

D. The Director of Compliance verified the findings in A. B. and C.