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Based on medical record review, policy review and staff interview it was determined the facility failed to ensure plans of care were reviewed and or updated after the use of restraints. This affected two of five medical records reviewed for the use of restraints. (Patient's #1 and #2) The census was 96.

Findings include:

Review of the facility policy titled, "Restraints" last reviewed on 11/2017 revealed "any use of restraint will be in accordance with a written modification of the patient's plan of care and implemented in accordance with the safe and appropriate restraint techniques as determined by OHP policy and state law." The patient and staff will participate in a debriefing about the restraint episode, which is important in reducing recurrent use. A comprehensive review and debriefing of staff and their performance shall also be completed on each restraint episode within 24 hours.


1. Review of Patient #1's medical record on 02/20/18 revealed an admission date of 01/26/18 with a diagnosis of schizophrenia. Review of the skilled nursing note dated 01/28/18 at 6:30 AM revealed the patient was yelling out, the nurse called the physician and the mental health aide attempted to verbally deescalate the patient. The patient then poured water out of the room, wrote on furniture, smeared toothpaste, began to take off clothes and walk into the hallway. Staff attempted to guide the patient back into his/her room while the nurse prepared medications to administer intramuscularly. Staff had to physically restrain the patient for the medication administration and again after due to the patient pushing another patient. Review of the physician orders dated 01/28/18 at 6:00 AM revealed an order for Haldol (Antipsychotic medication) 5 milligrams (MG) intramuscularly (IM) every six hours and Ativan 2 mg IM every six hours for agitation. Another physician order was received on 01/28/18 at 7:00 AM for Benadryl (antihistamine) 50 mg IM every six hours for agitation.

Review of the plan of care initiated on 01/26/18 revealed no evidence the plan of care had been reviewed or updated after the patient was restrained on 01/28/18.

This finding was verified with Staff B on 02/20/18 at approximately 2:36 PM. Staff B stated after patients are restrained the plan of care should be reviewed and a patient and staff debriefing should be completed.


2. Review of Patient #2's medical record on 02/20/18 revealed an admission date of 01/14/18 with a diagnosis of major depressive disorder with psychosis. Review of the skilled nursing noted dated 01/21/17 at 6:20 PM revealed the patient became angry, tossing chairs, tables and trash cans. Staff physically restrained the patient and the patient was given Haldol (antipsychotic) 10 mg and Benadryl (antihistamine) 50 mg IM. The patient sat for five minutes then got up and began punching toward staff and again the patient was physically restrained. Ativan (antianxiety) 1 mg IM was administered.

Review of the plan of care initiated on 01/14/18 revealed no evidence the plan of care had been reviewed or updated after the patient was restrained on 01/21/18.

This finding was verified with Staff A on 02/20/18 at approximately 4:06 PM.

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure patients and staff were debriefed after the use of restraints as per facility policy and procedure. This affected three of five medical records reviewed for use of restraints. (Patient's #1, #2, and #5) The census was 96.

Findings include:

Review of the facility policy titled, "Restraints" last reviewed on 11/2017 revealed "any use of restraint will be in accordance with a written modification of the patient's plan of care and implemented in accordance with the safe and appropriate restraint techniques as determined by OHP policy and state law." The patient and staff will participate in a debriefing about the restraint episode, which is important in reducing recurrent use. A comprehensive review and debriefing of staff and their performance shall also be completed on each restraint episode within 24 hours.

1. Review of Patient #1's medical record on 02/20/18 revealed an admission date of 01/26/18 with a diagnosis of schizophrenia. Review of the skilled nursing noted dated 01/28/18 at 6:30 AM revealed the patient was yelling out, the nurse called the physician and the mental health aide attempted to verbally deescalate the patient. The patient then poured water out of the room, wrote on furniture, smeared toothpaste, began to take off clothes and walk into the hallway. Staff attempted to guide the patient back into his/her room while the nurse prepared medications to administer intramuscularly. Staff had to physically restrain the patient for the medication administration and again after due to the patient pushing another patient. Review of the physician orders dated 01/28/18 at 6:00 AM revealed an order for Haldol (antipsychotic medication) 5 milligrams (MG) intramuscularly (IM) every six hours and Ativan (antianxiety medication) 2 mg IM every six hours for agitation. Another physician order was received on 01/28/18 at 7:00 AM for Benadryl (antihistamine medication) 50 mg IM every six hours for agitation.

Review of the medical record revealed no patient or staff debriefing was completed. This finding was verified with Staff B on 02/20/18 at approximately 2:36 PM. Staff B stated after patients are restrained a patient and staff debriefing should be completed.


2. Review of Patient #2's medical record on 02/20/18 revealed an admission date of 01/14/18 with a diagnosis of major depressive disorder with psychosis. Review of the skilled nursing note dated 01/21/17 at 6:20 PM revealed the patient became angry, tossing chairs, tables and trash cans. Staff physically restrained the patient and the patient was given Zyprexa (medication used to treat psychotic conditions) 10 mg and Benadryl (antihistamine medication) 50 mg IM. The patient continued with aggressive behaviors, hitting staff and an order for four point restraints was obtained.

Review of the medical record revealed no evidence that a patient or staff debriefing was completed. This finding was verified with Staff A on 02/20/18 at approximately 4:00 PM.


3. Review of Patient #5's medical record on 02/20/18 revealed an admission date of 12/05/17 with a diagnosis of major depressive disorder. Review of the skilled nursing noted dated 12/05/17 at 11:17 PM revealed the patient became angry, threw coffee and punched a staff member. Staff physically restrained the patient and the patient was given Haldol (antipsychotic medication) 10 mg and Benadryl (antihistamine medication) 50 mg IM. The patient sat for five minutes then got up and began punching toward staff and again the patient was physically restrained. Ativan (antianxiety medication) 1 mg IM was administered.

Review of the medical record revealed no evidence that a patient or staff debriefing was completed. This finding was verified with Staff A on 02/20/18 at approximately 4:06 PM.