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Based on interview and record review, the facility failed to ensure that 2 of 8 patients (Patient #3 and Patient #11) were seen face-to-face within one hour after the administration of an emergency medication by a physician or other licensed practitioner or a registered nurse trained in the face-to-face evaluation.

Findings included:

Record review of the Policy No. POC - N145, "Proper Use and Monitoring of Restraint, Emergency Medications, and Seclusion," last reviewed 2/2021, showed: " ... Purpose: To assure compliance with all laws, rules, and regulations relating to federal and state health care programs ... 5.0 Face to Face Evaluation by the Physician, LIP, or trained RN/PA: Within one hour of the initiation of restraint, seclusion, or emergency medication, the patient shall be evaluated in person by a physician, authorized LIP (Physician Assistant or Nurse Practitioner), or trained RN/PA ..."

Record review of the "Seclusion/Restraint/Emergency Medication" packet for Patient #3 showed that an unidentified emergency medication was ordered by Staff S (MD) and administered by Staff R (RN) on 7/11/2021 at 8:10pm. In addition, the packet showed that the "Post Intervention Face to Face Evaluation (to be completed within one hour of initiation of intervention)" had not been conducted.

Record review of the "Seclusion/Restraint/Emergency Medication" packet for Patient #11 showed that an unidentified emergency medication was ordered by Staff S (MD) and administered by Staff R (RN) on 7/11/2021 at 8:10pm. In addition, the packet showed that the "Post Intervention Face to Face Evaluation (to be completed within one hour of initiation of intervention)" had not been conducted.

In an interview with Staff C (Interim CNO) on 7/21/2021 at 2:00pm, she stated the trained RN should have conducted the Post Intervention Face to Face Evaluation within one hour of initiation of the administration of the emergency medication.