HospitalInspections.org

Based on medical record review and staff interview it was determined that six (6) of eight (8)
Psychiatric Evaluations there was a failure to describe patient assets in descriptive not
interpretative fashion. This failure results in no information being identified of personal
interests, achievements, pastimes, or other attributes, etc. that might be utilized in therapeutic
endeavors. (Patients A1, A3, A4, B1, B2 and B4)

The findings include-----

I. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 9/9/2016 had as the patient's sole asset "Faith in God", There was no elaboration as to how this might be utilized in therapeutic endeavors.

2. Patient A3: The Psychiatric Evaluation dated 9/8/2016 had as the patient's assets "...the
patient has an [sic] help seeking attitude and family support."

3. Patient A4: The Psychiatric Evaluation dated 9/7/2016 stated as the patient's asset "evidenced by a help seeking attitude and family support."

4. Patient B1: The Psychiatric Evaluation dated 9/8/2016 had as the sole identified asset
"healthy". There was no elaboration for this hospitalized patient as to how this would be possibly utilized in therapeutic endeavors.

5. Patient B2: The Psychiatric Evaluation dated 9/10/2016 stated as patient assets "Social
support----active step-mother involved in tx (treatment)."

6. Patient B4: The Psychiatric Evaluation dated 9/8/2016 stated for assets "getting along with
other people, learning things." What "things" might be of interest for this patient was not
elaborated.

II. Staff Interview:

On 9/16/2016 at 9:30 a.m. the clinical director and the facility's Quality Assurrance staff member were interviewed. When told of the findings described in Section I, above, the clinical director stated that he understood the necessity of describing patient inherent attributes in a concrete manner and these were not adequately descriptive. He agreed that the statement "faith in God" as an asset was not sufficiently descriptive of how the psychiatrist might build treatment modalities.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTP) contained individualized short-term goals that were relevant to the psychiatric condition of eight (8) of eight (8) active sample patients (A1, A2, A3, A14, B1, B2, B3, and B4).

Specifically, goals were not stated in behavioral and measurable terms that would be necessarily understood by the patient. In addition, MTPs contained statements that listed non-specific psychiatric jargon rather than patient outcome behaviors to show what the patient would do or say to show improvement in the severity of the identified psychiatric problems. Failure to identify individualized goals potentially hampers the treatment team's ability to determine patients' goal attainment, progress, or whether the treatment is effective.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (9/9/16); A2 (9/9/16); A3 (9/9/16); A4 (9/9/16); B1 (9/9/16); B2 (9/12/16); B3 (9/12/16); and B4 (9/9/16).

This review revealed that the following deficient objectives formulated by physicians (MD),
registered nurses (RN), social workers (SW), and recreational therapists (RT). Short-term (STG) were not individualized or stated as measurable behavioral patient outcomes based on unique information from clinical assessments. Several short-term goals for different patients were identical or similarly worded.

1. Active sample patient A1's MTP included psychiatric problem #1: "Depression - Evidenced by: SI [Suicidal Ideation] [without] plan... poor hygiene hopeless." The deficient STGs were:

a. MD: "No suicidal thoughts x [times] 4 days." This STG did not include unique information
about this patient's suicidal thoughts. This was more of a discharge criteria rather than a STG to reflect behavior outcomes related to what the patient would do or say to show understanding and management of the identified suicidal thoughts.

b. SW: "Pt [Patient] will implement 2 skills for improving mood and reducing sadness."

c. RT: "Pt [Patient] will identify 2 skills to manage depression and reducing sadness."
The STGs for SW and AT both contained general psychiatric jargon and were not measurable or written in behavioral terms; therefore it would be difficult for staff to know what behaviors to observe to determine goal attainment.

2. Active sample patient A2's MTP included psychiatric problem #2: "Depression - Evidenced by: Suicidal Ideation... plan to shoot self if had a gun." The deficient STGs were:

a. MD: "[Patient's name] will increase mood to 6/10 or above." This STG was not
individualized. During an interview on 9/16/16, the Director of Social Work stated that the
patient completed a self-inventory each day. The form titled, "Patient Self Inventory" contained 13 items with a general statement using a 1 to 10 rating, "How would you rate how you are feeling today?" There was no description of how this patient manifested the
symptoms associated with mood.

b. RN: "Pt [Patient] will state 1 reason for living while in hospital."

c. SW: "[Patient name] will identify 2 triggers for depression and SI."

d. RT: "Pt [Patient] will identify 2 skills to manage depression symptoms and increase [sic]."

The STGs formulated by the RN, SW, and AT were very board, not measurable or written in behavioral terms; therefore it would be difficult for staff to know what behaviors to observe to determine goal attainment.

3. Active sample patient A3's MTP included psychiatric problem #1: "Psychotic Behavior -
Evidenced by: Wandering the streets at night." The deficient STGs were:

a. MD: "[Patient's name] will decrease delusions to one time or less per shift." This STG did not include a description regarding the content of this patient's delusions or how they affected the patient's behavior.

b. RN: "Pt [Patient] will establish and an adequate balance of rest, sleep & activity [sic] 3
days." This STG was not a patient outcome reflecting what the patient would be saying or doing to improve the identified psychiatric symptoms. This STG was also not related to information found in clinical assessments.

c. SW: "[Patient's name] will focus in group with appropriate attention and participate for at
least 10 min. [minutes]." This STG was not related to the patient's identified psychiatric
problems.

d. RT: "[Patient's name] will identify 2 leisure activities to improve quality of life." This STG
was very broad and did not show a specific relationship to the identified psychiatric problems.

4. Active sample patient A4's MTP included psychiatric problem #1: "Depression - Evidenced by: Pt [Patient] took 40 tabs of 2 mg. Klonopin & 12 tabs of Ambien 10 mg. 2 days ago." The deficient STGs were:

a. MD: "[Patient's name] will decrease suicidality to thoughts less than one per day." This STG was not written in behavioral terms.


b. RN: "Pt [Patient] will participate in medication evaluation." This STG was a staff expectation rather than a behavioral patient outcome regarding understanding his/her medications, benefits, and sign effects.

5. Active sample patient B1's MTP included psychiatric problem #1: "Depression - Evidenced by: Suicidal Ideation...SI [with] plan to cut wrist." The deficient STGs were:

a. MD: "No thoughts of SI by 0 Day 5." This was not individualized or a patient outcome
reflecting this patient's unique circumstances and what the patient would be saying or doing to
improve presenting psychiatric symptoms.

b. RN: "[Patient's name] will identify two precipitating factors which increase thoughts of suicide or self harm." This STG was identical or similarly worded to the goal formulated for Patient B4. It also did not include action behaviors (what the patient would do or say to show he/she understand how to manage factors leading to suicidal thoughts.

c. SW: "[Patient name] will identify 2 coping skills for depression symptoms reacting to family
issues." This STG was very board without any unique descriptors of how the patient manifested symptoms of depression. Therefore, it would be difficult for staff to know what behaviors to observe to determine goal attainment.

6. Active sample patient B2's MTP included psychiatric problem #1: "Aggressive Behaviors - Evidenced by: Kicked mother of child in stomach 25 wk [week] pregnant). Pt [Patient] states "I need help controlling my anger." The deficient STGs were:

a. MD: "[Patient's name] will increase to 6/10 or above by DC." This was not a patient outcome reflecting what the patient would be saying or doing to improve presenting psychiatric symptoms.

c. SW: "[Patient name] will identify 2 coping skills to reduce aggressive behaviors." The STG was not measurable or written in behavioral terms; therefore it would be difficult for staff to know what aggressive behaviors to observe to determine goal attainment.

7. Active sample patient B3's MTP included psychiatric problem #1: "Depression - Evidenced by: Suicidal Ideation...I planned to OD." The deficient STGs were:

a. MD: "Resolve SI [sic]& dep. [depression] inc. [increase] mood to 7/10." This STG was not written in observable, measurable, or behavioral terms.

b. RN: "Pt [Patient] will develop healthy habits to decrease feelings of self harm and will rate
mood [greater than] 5 by day 3 [after] adm [admission]." This STG did not include action
behavior (what the patient would do or say to show he/she understand how to manage factors leading to suicidal thoughts.

c. SW: "[Patient name] will identify 2 coping skills for depression symptoms reacting to family issues." This STG was not individual, board without descriptors of depressive symptom, and was also identical or similarly worded to goal formulated for Patient B1.

8. Active sample patient B4's MTP included psychiatric problem #1: "Depression - Evidenced by: Suicidal Ideation... Suicidal thoughts to overdose. Denies actual attempts/gestures recent [sic]. Self destructive behavior/potentially harmful behaviors...Self mutilates was x [times] 3-4 wks [weeks] ago." The deficient STGs formulated were:

a. MD: "Resolve SI [Suicidal Ideation]." This STG was not written in observable, measurable, or behavioral terms.

b. RN: "[Patient's name] will identify two precipitating factors which increase thoughts of suicide [sic] self harm." This STG did not include action behavior (what the patient would do or say to show he/she understand how to manage factors leading to suicidal thoughts.

c. SW: "[Patient name] will identify 2 psychosocial strengths to help build self-esteem." This
STG was not an individualized statement and very board.

B. Interviews

1. In an interview on 9/14/16 at 2:05 p.m. with SW #1, Patient A3's MTP was discussed. SW #1 stated that she understood that the STG regarding the patient participating in group was not related to the patient's identified psychiatric problems. She acknowledged that several STGs were very broad and general. She agreed that it would be difficult to determine goal attainment because goal statements were not behaviorally descriptive of the patient's identified psychiatric problems.

2. In an interview on 9/15/16 at 12:40 p.m. with RT #1, MTPs plans were discussed. She
acknowledged that some STGs were not individualized or related to the patient's identified
problem. She recognized that they were not measureable or written in behavioral terms. She
stated, "I usually add more information in the problem statement based on my assessment so the goal is related to the patient's problem."

3. In an interview on 9/15/16 at 3:40 p.m. with the Director of Social /Recreational Therapy, MTPs for Patient A1, A2, A3, and A4 were discussed. She agreed that short-term goal statements were not individualized.

4. In an interview on 9/15/15 at 4:10 p.m. with the Director of Nursing, MTPs for Patient A1, A2, A3, and A4 were discussed. She did not dispute the findings that several STG statements were not individualized or related to the patients' identified psychiatric problems.

Based on record review and interview, the facility failed to ensure that Master Treatment Plans (MTPs) contained individualized treatment interventions with a focus or purpose based on identified psychiatric problems and treatment goals of eight (8) of eight (8) active sample patients (A1, A2, A3, A14, B1, B2, B3, and B4). Instead, MTPs included routine discipline functions and/or non-specific statements rather than specific modalities that reflected contact with patients to involve and engage them in active treatment measures to address their identified psychiatric problems. This deficiency results in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention and potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (9/9/16); A2 (9/9/16); A3 (9/9/16); A4 (9/9/16); B1 (9/9 /16); B2 (9/12 /16); B3 (9/12/16); and B4 (9/9/16). This review revealed that the following interventions were non-specific and/or routine discipline functions, and not individualized. Intervention statements were identified for the following disciplines: (Physician (MD), Registered Nurse (RN), Social Worker (SW), and Recreational Therapy (RT).

1. Patient A1's MTP had following deficient statements written as active treatment interventions for problem #1: "SI [Suicidal Ideation] [without] plan...poor hygiene hopeless."

MD Intervention: "Adjust medications." This intervention was to be delivered in 1:1 sessions
"daily." This was a routine MD functions and failed to identify targeted psychiatric medications or specify contact to assist the patient to understand his/her medications, benefits, and sign effects.

RN Intervention: "RN will assist pt [patient] in identifying reasons for wanting to live." This
intervention was to be delivered in 1:1 sessions "daily." This intervention was not individualized and was identical or similarly worded for Patient A2.

SW Intervention: "The therapist will implement 2 skills [with] pt [patient] for coping with
depression." This intervention was to be delivered in group sessions "7x/week." This intervention was not individualized and failed to identify specify symptoms of depression that would be the focus of coping strategies.

RT Intervention: "RT [Recreation Therapy] will lead group on healthy skills." This intervention was related to a staff function rather than a behavioral patient outcome based treatment goals and/or identified psychiatric problems. This intervention was also identical or similarly worded for active Patients A1, A2, and B2.

2. Patient A2's MTP had following deficient statements written as active treatment interventions for problem #2: "Depression - Evidenced by: Suicidal Ideation...plan to shoot self if had a gun."

MD Intervention: "Assist pt [patient] to identify [sic], med [medication] eval evaluation]/titrate." This intervention was to be delivered in 1:1 sessions "daily." This statement was not individualize and did not include any active treatment interventions to involve patients and assist him/her with the improvement of the identified psychiatric problems.

RN Intervention: "RN will help identify [with] pt [patient] (1) reason for living daily." This
intervention was to be delivered in 1:1 sessions "daily." This intervention was not individualized and was identical or similarly worded for Patients A1 and A2.

SW Intervention: "Clinician will educate on healthy coping skills." This intervention was to be
delivered in group sessions "daily". This intervention statement was not individualized and did
not identify which coping skills or activities would be the focus of interventions based on this
patient's unique circumstances, needs, and/or triggers of suicidal thinking and/or behaviors.

RT Intervention: "RT [Recreation Therapy] will lead group on leisure education." This
intervention was to be delivered in group sessions "5x [times]/wk [week]." This was a RT
function and did not include anticipated focus of leisure education based this patient's needs and unique circumstances.

3. Patient A3's MTP had following deficient statements written as active treatment interventions for problem #1: "Psychotic Behavior - Evidenced by: Wandering the streets at night."

MD Intervention: "MD will assess effectiveness of Latuda and need for titration." This
intervention was to be delivered in 1:1 "daily."

RN Intervention: "Nurse will observe [Patient's name] for signs of fatigue & monitor [his/her]
sleep pattern & provide opportunities for rest during the day as needed." This intervention was to be delivered in 1:1 sessions "Q [Every] shift & PRN." This intervention was a routine nursing function and was not related to the patient's identified psychiatric problem.

SW Intervention: "Clinician will assist [Patient's name] in engaging in here and now activities,
education and skill building." This intervention was to be delivered in groups sessions "7 x
weekly." The intervention statement was non-specific and not individualized to reflect a focus
related to the patient's identified psychiatric problems.

RT Intervention: "RT [Recreation Therapy] will provide education on leisure activities." This
intervention was to be delivered in groups sessions "5x [times]/week." This intervention failed to identify a focus of leisure activities based on the circumstances and needs identified in clinical assessment or presenting problems.

4. Patient A4's MTP had following deficient statements written as active treatment interventions for problem #1: "Depression - Evidenced by: Pt [Patient] took 40 tabs of 2 mg. Klonopin & 12 tabs of Ambien 10 mg. 2 days ago."

MD Intervention: "MD will assess [Patient's name] level of suicidality." This intervention was to be delivered in 1:1 sessions "daily." This intervention was a routine MD function rather than a focus of contact to provide the patient information about his/her suicidality and strategies to manage the identified psychiatric problems.

RT Intervention: "RT [Recreation Therapy] will educate on healthy distractions." This
intervention was to be delivered in group sessions "5x [times]/week." This intervention was very broad and not specifically related to the patient's psychiatric problems.

5. Patient B1's MTP had following deficient statements written as active treatment interventions for problem #1: "Depression - Evidenced by: Suicidal Ideation...SI [with] plan to cut wrist."

MD Intervention: "Review coping skills. Medication eval. [evaluation], MSE [Mental status
evaluation]." This intervention was to be delivered in 1:1 sessions "daily 15 - 20." These
interventions were not individualized and were routine MD functions except for reviewing
coping skills. However, the statement failed to include the focus of coping skills based on this
patient's unique needs.

RN Intervention: "Help pt [patient] identify stressors and circumstances that trigger thoughts of suicide or self harm." This intervention was to be delivered in 1:1 sessions "1x [time] per shift."

SW Intervention: "Clinician will provide psycho educational information on triggers, warning
signs, & coping skills. This intervention was to be delivered in group sessions "7x [times] wkly [weekly]." This intervention statement was not individualized and failed to specify a focus of treatment reflecting the patient's targeted psychiatric problems.

RT Intervention: "RT [Recreation Therapy] will provide group on healthy coping skills." educate on healthy distractions. This intervention was to be delivered in groups sessions "5x [times]/week." This intervention statement did not include the anticipated focus of healthy
coping skills based this patient's presenting problems, needs ,and unique circumstances.

6. Patient B2's MTP had following deficient statements written as active treatment interventions for problem #1: "Aggressive Behaviors - Evidenced by: Kicked mother of child in stomach 25 wk [week] pregnant). Pt [Patient] states "I need help controlling my anger."

MD Intervention: "Daily MSE [Mental Status Evaluation], Medication eval. [evaluation]." This intervention was to be delivered in individual sessions daily for "20" minutes.

SW Intervention: "Therapist will educate [sic] on anger management." This intervention was to be delivered in group sessions and the frequency was illegible. The focus of this intervention was non-specific and failed to identify appropriate education based on the patient's unique circumstances and needs.

RT Intervention: "RT [Recreation Therapy] will lead group on healthy skills for anger
management." This intervention was to be delivered in group sessions "5x [times]/weekly" for 60 minutes. This was a RT function and did not include anticipated focus of healthy skills based this patient's needs and unique circumstances anger.

7. Patient B3's MTP had following deficient statements written as active treatment interventions for problem #1: "Depression - Evidenced by: Suicidal Ideation...I planned to OD."

MD Interventions: "Titrate meds [medications], MSE [Mental Status Evaluation] daily." This
intervention was to be delivered in individual sessions daily for "20" minutes. All of these
interventions were normal clinical functions of the M.D./designate, and do not have any specific focus related to this patient's specific problems.

SW Intervention: "Clinician will provide psycho education information on triggers, warning
signs, coping skills." This intervention was to be delivered in groups sessions 7x [times] wkly
[weekly] for 60 minutes. There was no specificity regarding triggers, warning signs, and the
types of coping skills to be addressed based on the patient's psychiatric problems, needs and
unique circumstances. This was not individualized because this statement was identical or similarly worded for active patient B1.

RT Intervention: "RT [Recreation Therapy] will provide group on stress management." This
intervention was to be delivered in groups sessions 5x [times]/weekly for 1 hr. [hour]. This was a RT function and did not include anticipated focus of stress management based this patient's assessed needs and unique circumstances.

8. Patient B4's MTP had following deficient statements written as active treatment interventions for problem #1: "Depression - Evidenced by: Suicidal Ideation...Suicidal thoughts to overdose. Denies actual attempts/gestures recent [sic]. Self destructive behavior/potentially harmful behaviors...Self mutilates was x [times] 3-4 wks [weeks] ago.

MD Intervention: "Develop coping skills, med [medication] management." This intervention was to be delivered in individual & group sessions daily for "10-15" minutes. The statement
regarding developing coping skills was non-specific in that it did not specific the focus of the
coping skills. Medication management was a normal clinical function of the M.D.

RN Intervention: "Help pt [patient] to identify stressors and circumstances that triggers thoughts of suicide or self -harm."

SW Intervention: "Clinician will teach skills and help pt identify strengths." This intervention
was to be delivered in groups sessions 7x [times] wkly [weekly] for 1 hour.

RT Intervention: "RT [Recreation Therapy] will provide group on healthy coping skills." This
intervention was to be delivered in groups sessions 5x [times]/week for 1 hour. This intervention was identical or similarly worded for Patients

B. Interviews

1. In an interview on 9/15/16 at 12:40 p.m. with RT #1, MTPs plans were discussed. She
acknowledged that the RT intervention statement "lead group on healthy skills" was non-specific and not individualized. She also agreed that many RT statements were identical or similarly worded.

2. In an interview on 9/15/16 at 3:40 p.m. with the Director of Social /Recreational Therapy,
MTPs for Patient A1, A2, A3, and A4 were discussed. She agreed that focus statements such as "implementing 2 skills with patient for coping with depression" was very broad and not individualized. When reviewing the RN intervention for Patient A3, She agreed that it was not related to the patient's problem and stated, "We are monitoring 100% of treatment plan and I will meet with staff who wrote this."

4. In an interview on 9/15/15 at 4:10 p.m. with the Director of Nursing, MTPs for Patient A1, A2, A3, and A4 were discussed. She did not dispute the findings that several intervention statements were not individualized or related to the patients' identified psychiatric problems.

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) active sample patients and five (5) of five (5) non-sample patients there were written standing physician Orders for "Hydroxyzine 25 mg po (by mouth) q6h (every 6 hours) prn (as necessary) anxiety" and "Olanzapine 5 mg Zydis/ODT PO q8h PRN psychotic agitation or hallucinations" to be administered based on nursing staff assessment of patient's symptoms and the frequency to administer them as well as should they be used separately or in combination. This failure results in requiring the nursing staff to diagnose and prescribe which is outside their scope of practice. (Patients A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3, C4 and C5).

The findings include----

I. Medical Record Review:

1. Patient A1: The Adult Physician Admission Order Form dated 9/8/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnosis of psychotic symptoms.

2. Patient A2: The Adult Physician Admission Order Form dated 9/8/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnosis of psychotic symptoms.

3. Patient A3: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis.

4. Patient A4: The Adult Physician Admission Order Form dated 9/7/2016 had only the
Hydroxyzine order to be used on a prn basis.

5. Patient B1: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had been given both Hydroxyzine and Olanzapine on 9/11/2016. This patient had no diagnoses of psychotic features.

6. Patient B2: The Adult Physician Admission Order Form dated 9/9/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnoses of psychotic features.

7. Patient B3: The Adult Physician Admission Order Form dated 9/9/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnoses of psychotic features.

8. Patient B4: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. Patient ' s mother did not consent for the use of Hydroxyzine. This patient had no diagnoses of psychotic features yet had a standing Order for the use of an antipsychotic medication on a prn basis.

9. Patients C1 (date of Order sheet in parenthesis) (9/14/2016), Patient C2 (9/14/2016, Patient C3 (9/14/2016) and Patient C4 (9/14/2016) all had available the Orders for Hydroxyzine and Olanzapine on a prn basis.

10. Patient C5: The Adult Physician Admission Order Form dated 9/14/2016 had both
Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient did not have a
diagnosis of psychotic features.

II. Staff Interview:

On 9/14/2016 at 3:25 p.m. RN#1 told the surveyor "All the adolescent standing Orders are the same. I guess it is a nursing judgment" i.e. which medication to select and what patient
symptoms necessitated the use of an antianxiety agent (Hydroxyzine) and/or antipsychotic agent (Olanzapine).

2. On 9/15/2016 at 10:00 a.m. the clinical director, the Director of Nursing and the Director of Social Services met with the surveyors. The clinical director did not dispute that the phenomena of standing physician Orders for antipsychotic medications was a facility-wide practice. The clinical director acknowledged that as written these Orders necessitated nursing staff to function outside their scope of practice.

3. On 9/16/2016 at 9:30 a.m. the clinical director and the Quality Assurance staff member met. The clinical director again agreed with the findings. The Quality Assurance staff member reported to the surveyor that she had been instructed to remove these standing Orders including the one for "Trazadone 50mg PO qhs (every sleep time) PRN sleep {sic}: May repeat dose x1 after 1 hour if still awake" as of 9/15/2016 early afternoon.

4. When the use of an antipsychotic medication for a patient without psychotic symptoms or
diagnoses happens this is a form of chemical restraint. On 9/16/2016 at 10:55 a.m. the Director of Nursing told the surveyor that to the best of her knowledge no chemical restraints had occurred over the last 2 weeks. Thus, the facility did not consider these Olanzapine Orders as a form of chemical restraint (see occurrence for Patient B1). At 11:30 a.m. the Director of Nursing assured the surveyor that this form of usage is a method for chemical restraint and would be reported as such.