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Based on policy review, medical record review and interview, the facility failed to modify the treatment plan to reflect the use of restraints and/or seclusion; failed to have a face-to-face assessment within 1 hour after the initiation of an intervention; failed to describe in descriptive terms the behavior and interventions used to evaluate the appropriateness of the intervention; failed to document the imminent danger behavior that warranted a restraint/seclusion intervention; and/or failed to document a detailed assessment of the patient's response to the restraint/seclusion for 3 of 3 (Patient #1, #2 and #3) sampled patients who displayed behaviors requiring interventions.

The findings included:

1. Patient #1 was voluntarily admitted to the hospital on 3/19/2021 for Medically Assisted Detoxification from Alcohol and Opioids.
Patient #2 was admitted to the hospital on 2/9/2021 with a diagnosis of Bipolar Disorder Severe.
Patient #3 was admitted to the hospital 1/4/2021 with a diagnosis of Schizoaffective Disorders.
See A166 for additional information regarding the admission of Patient #1, #2 and #3.

2. The hospital failed to modify Patient #1, #2 and #3's treatment plan to reflect the use of restraints and/or seclusion.
See A166 for addition information regarding the hospital's failure to modify the patient's treatment plan.

3. The hospital failed to assess Patient #1 and #3 face-to-face within 1 hour after the initiation of a restraint and/or seclusion intervention for behaviors exhibited.
See A179 for additional information regarding the hospital's failure to modify the patient's treatment plan to reflect the use of restraints and/or seclusion.

4. The hospital failed to document the behavior and intervention used in descriptive terms to evaluate the appropriateness of the intervention; the hospital failed to identify the physical and mental status assessments and any environmental factors that may have contributed to the behavior that required intervention.
See A185 for additional information regarding the assessment of physical and mental status as well as environmental factors that may have contributed to behaviors requiring intervention.

5. The hospital failed to identify and document the patient's condition or symptoms that warranted the use of restraints; and failed to document criteria for release of restraints.
See A187 for additional information regarding the condition or symptoms that warranted the use of restraints as well as criteria for release of restraints.

Based on policy review, medical record review and interview the hospital failed to ensure patient's treatment plan was revised and updated to reflect the use of restraint and/or seclusion for 3 of 3 (Patient #1, #2 and #3) patients requiring the use of restraints and/or seclusion.

The findings included:

1. Review of the hospital's "Restraint/Seclusion" policy revealed, "...The patient's treatment plan should be updated to include information from the patient and staff debriefings in order to reduce the use of restraint/seclusion..."

2. Record review for Patient #1 revealed an admission date of 3/19/2021. Patient #1 was voluntarily admitted for Medically Assisted Detoxification from Alcohol and Opioids.

The Medication Administration Record (MAR) dated 3/20/2021 at 10:48 PM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 miiligram (mg) intramuscular (IM) and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint.

Review of the hospital's Nursing Progress Notes dated 3/20/2021 at 11:08 PM, revealed Registered Nurse (RN) #5 documented Ziprasidone and Lorazepam were administered because Patient #1 was "...argumentative and manipulative and would not be directed away from nurse's station. He demanded a cigarette and demanded to go outside...Supervisor was contacted and talked repeatedly with patient..."

Review of the MAR dated 3/21/2021 at 10:11 AM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 mg IM and Diphenhydramine (Benadryl) 50 mg injectable for Agitation

Review of the hospital's Nursing Progress Notes dated 3/21/2021 at 10:23 AM, revealed RN #6 documented Ziprasidone and Lorazepam were administered because Patient #1 was "...patient is agitated and verbally aggressive. He is paranoid and delusional, thinking someone was going to steal a bottle of alcohol from his room...Received order for chemical restraint due to agitation..."

Review of the hospital's Restraint/Seclusion Intervention form dated 3/23/2021 at 11:00 PM, revealed RN #1 documented, "...Patient imminent danger to others...patient threatening to throw chairs, disruptive to the unit..."

Review of the MAR dated 3/23/2021 at 11:04 PM, revealed Patient #1 was administered Olanzapine (Zyprexa) 10 mg IM Diphenhydramine (Benadryl) 50 mg IM Now for agitation.

There was no documentation the treatment plan was modified to reflect a change in Patient #1's plan of treatment based on a process of assessment, intervention and evaluation to identify the need for medication/chemical restraint.

3. Record review for Patient #2 revealed an admission date of 2/9/2021 with a diagnosis of Bipolar Disorder Severe.

Review of the MAR dated 2/10/2021 at 1:22 AM, revealed Patient #2 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint

Review of the hospital's Restraint/Seclusion Intervention form dated 2/10/2021 at 1:30 AM, revealed RN #7 documented Ziprasidone and Lorazepam were administered because Patient #2 was "...increasingly agitated yelling, wandering into other people's rooms-not responding to staff attempts to redirect..."

There was no documentation the treatment plan was modified to reflect a change in the Patient #2's plan of treatment based on a process of assessment, intervention and evaluation to identify the need for medication/chemical restraint.

4. Medical record review for Patient #3 revealed an admission date of 1/4/2021 with a diagnosis of schizoaffective disorders.

Review of the MAR dated 1/4/2021 at 11:52 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/4/2021 at 11:52 PM, revealed Patient #3 was placed in Seclusion starting on 1/4/2021 at 11:55 PM and was removed from seclusion on 1/5/2021 at 1:20 AM for a total time of 1 hour and 25 minutes.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/5/2021 at 10:07 PM, revealed Patient #3 was placed in a hold starting on 1/5/2021 at 10:07 PM, and ending at 1/5/2021 at 10:09 PM, for a total of 2 minutes. RN #3 documented, "...Imminent danger to self and imminent danger to others, pt [patient] psychotic...patient attempted to hit numerous staff multiple times..."

Review of the MAR dated 1/5/2021 at 10:12 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint.

Review of the MAR dated 1/8/2021 at 9:00 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/8/2021 at 9:00 PM, revealed Patient #3 was administered a Medication/Chemical Restraint. RN #7 documented, "...Imminent danger to self and imminent danger to staff...pt verbally and physically aggressive towards staff, forcefully pushed a chair into the wall slamming door..."

Review of the MAR dated 1/9/2021 at 7:29 PM, revealed Patient #3 was administered Diphenhydramine 50 mg IM and Lorazepam (Ativan) 2 mg IM as a now order for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/9/2021 at 7:30 PM, revealed Patient #3 was placed in a hold starting on 1/9/2021 at 7:30 PM, and was released on 1/9/2021 at 7:47 PM, for a total of 17 minutes. RN #1 documented, "...Imminent danger to others...Pt screaming attempted to throw a chair, slapped the MHS [Mental Health Specialist] and threw his glases..."

Review of the hospital's Restraint/Seclusion Intervention form dated 1/10/2021 at 1:00 AM, revealed RN #1 documented, "...Imminent danger to self and Imminent danger to others, verbally threatening, refusing to go back to her room. Patient is impulsive, slapping MHS so hard that his glasses and mask flew off..."

Review of the MAR dated 1/10/2021 at 1:18 AM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a now order for agitation.

Review of the MAR dated 1/10/2021 at 9:37 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a now order for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/10/2021 at 9:39 PM revealed RN #11 documented, "...Imminent danger to self and Imminent danger to others, patient was impulsive and acting out threatening others..."

Review of the hospital's Restraint/Seclusion Intervention form dated 1/11/2021 at 11:05 AM, revealed RN #9 documented, "...Imminent danger to others, patient yelling very loudly and threatening staff ad has been throwing objects from the desk..."

Review of the MAR dated 1/11/2021 at 11:06 AM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a Medication/Chemical Restraint.

Review of the MAR dated 1/12/2021 at 8:38 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM as a now order for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/12/2021 at 9:24 PM, revealed RN #2 documented, "...Patient was very agitated which had been going on all day. She continued to escalate yelling, screaming at which ended when she pulled the light switch off the wall exposing electrical wiring, she was moved to another room and placed on one to one while awake..."

Review of the hospital's Restraint/Seclusion Intervention form dated 1/13/2021 at 6:01 PM, revealed Patient #3 was placed in a Seclusion starting on 1/13/2021 at 6:01 PM and was removed from seclusion on 1/13/2021 at 9:30 PM for a total time of 3 hours and 29 minutes. RN #2 documented, "...Imminent danger to self and imminent danger to others...Patient walking around nursing station yelling and screaming coming at staff stripping naked and tearing up scrubs given to her to put on..."

Review of the MAR dated 1/13/2021 at 7:21 PM, revealed Patient #3 was administered Diphenhydramine (Benadryl) 50 mg IM, Lorazepam (Ativan) 2 mg IM, and Haloperidol (Haldol) 5 mg IM as a now order for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/17/2021 at 10:10 AM, revealed RN #9 documented, "...imminent danger to others...patient threw her drink at nurse and was trying to attack nurse this attack was very impulsive in random..."

Review of the MAR dated 1/17/2021 at 10:25 AM revealed Patient #3 was administered Diphenhydramine (Benadryl) 50 mg IM, Lorazepam (Ativan ) 2 mg IM, and Haloperidol (Haldol) 5 mg IM as a Medication/Chemical Restraint.

There was no documentation the treatment plan was modified to reflect a change in the Patient #2's plan of treatment based on a process of assessment, intervention and evaluation to identify the need for medication/chemical restraint and holds for restraints and seclusion.

5. In an interview on 3/31/2021 at 2:15 PM, the Chief Operating Officer/Chief Nursing Officer verified treatment plans were not updated or revised after each Restraint/Seclusion incident for Patient's #1, #2 and #3.

Based on policy review, medical record review and interview the hospital failed to ensure patients were assessed face to face within 1 hour after the initiation of the intervention (Restraint/Seclusion) by a Physician, Qualified Registered Nurse (QRN) or other Licensed Independent Practitioner (LIP) to include both a physical and behavioral assessment for 2 of 3 (Patient #1 and #3) patient's requiring restraint and/or seclusion.

The findings included:

1. Review of the hospital's "Restraint/Seclusion" policy revealed, "... A Physician, Qualified Registered Nurse or other Licensed Independent Practitioner as allowed by law and scope of practice conducts an in-person face to face assessment of the patient in restraints/seclusion within one hour of initiation and documents findings on the One Hour Face to Face Evaluation...The purpose of this evaluation by the LIP/QRN is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others ..."

2. Medical record review for Patient #1 revealed an admission date of 3/19/2021. Patient #1 was admitted voluntarily for Medically Assisted Detoxification from Alcohol and Opioids.

Review of the Medication Administration Record (MAR) dated 3/20/2021 at 10:48 PM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 milligrams (mg) Intramuscular (IM) and Lorazepam (Ativan) 2 mg IM for Medication/Chemical Restraint.

The hospital's Nursing Progress Notes dated 3/20/2021 at 11:08 PM, revealed Registered Nurse (RN) #5 documented medications were administered because Patient #1 was "...argumentative and manipulative and would not be directed away from nurse's station. He demanded a cigarette and demanded to go outside...Supervisor was contacted and talked repeatedly with patient..."

There was no documentation Patient #1 received a Face to Face Assessment within one hour after the initiation of the intervention on 3/20/2021.

Review of the MAR dated 3/21/2020 at 10:11 AM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 mg IM and Diphenhydramine (Benadryl) 50 mg IM for Medication/Chemical Restraint.

Review of the hospital's Nursing Progress Notes dated 3/21/2021 at 10:23 AM revealed the RN #6 documented medication were administered because Patient #1 was "...patient is agitated and verbally aggressive. He is paranoid and delusional, thinking someone was going to steal a bottle of alcohol from his room...Received order for chemical restraint due to agitation..."

There was no documentation Patient #1 received a Face to Face Assessment within one hour after the initiation of the intervention on 3/21/2021.

Review of the Nursing Progress Note dated 3/23/2021 at 9:29 PM revealed RN #1 documented, "...patient remains very manic...fighting sleep and demanding more medications...staff reports that the patient's behavior changed from orientation to confusion...it is very difficult to separate his polysubstance abuse, withdrawal medications and medications for agitation/threatening behavior..."

Review of the MAR dated 3/23/2021 at 11: 04 PM, revealed Patient #1 was administered (Olanzapine) Zyprexa 10 milligrams IM and Benadryl 50 milligrams IM for Medication/Chemical Restraint. Zyprexa is an antipsychotic medication used to treat psychotic conditions. Benadryl is an antihistamine medication that can be used for insomnia.

There was no documentation Patient #1 received a Face to Face Assessment within one hour after the initiation of the intervention on 3/23/2021.

3. Medical record review for Patient #3 revealed an admission date of 1/4/2021 with a diagnosis of schizoaffective disorders.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/5/2021 at 10:07 PM, revealed Patient #3 was psychotic, attempting to hit staff multiple times. Patient #3 was placed in a hold starting at 10:07 PM and was released at 10:09 PM for a total time of 2 minutes.

Review of the MAR revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM on 1/5/2021 at 10:12 PM as a Medication/Chemical Restraint.

There was no documentation Patient #3 received a Face to Face Assessment within one hour after the initiation of the intervention on 1/5/2021.

Review of the MAR revealed Patient #3 was administered Lorazepam (Ativan) 2 mg IM, Benadryl 50 milligrams IM and Haloperidol 5 mg IM on 1/9/2021 at 7:29 PM for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/9/2021 at 7:30 PM, revealed RN #1 documented medications were given because Patient #3 was "...extremely manic, running, screaming, attempted to throw a chair and slapped a MHS [Mental Health Specialist]. Patient #3 was placed in a hold at 7:30 PM through 7:47 PM for a total of 17 minutes.

There was no documentation Patient #3 received a Face to Face Assessment within one hour after the initiation of the intervention on 1/9/2021.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/13/2021 at 6:01 PM, revealed Patient #3 was walking around the nursing station yelling and screaming, coming at staff, stripping naked and tearing up scrubs given to her to put on. Patient #3 was placed in seclusion at 6:01 PM and out of seclusion at 9:30 PM for a total time of 3 hours and 29 minutes.

Review of the MAR dated 1/13/2021 at 7:33 PM revealed Patient #3 was administered Benadryl 50 mg IM, Ativan 2 mg IM and Haldol 5 mg IM as a now dose for agitation.

There was no documentation Patient #3 received a Face to Face Assessment within one hour after the initiation of the intervention on 1/13/2021.

4. In a telephone interview on 4/5/2021 at 11:00 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation Patient #1 received a Face to Face Assessment within one hour after the initiation of the intervention related to Medication/Chemical restraints on 3/20/2021, 3/21/2021 and 3/24/2021 stating, "...It was missed."

5. In a telephone interview on 4/5/2021 at 11:30 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation Patient #3 received a Face to Face Assessment within one hour after the initiation of the intervention related to Medication/Chemical/Holds Restraints on 1/5/2021, 1/9/2021 and 1/13/2021.

Based on policy review, medical record review and interview the hospital failed to document the description of the patients behavior and the intervention used in descriptive terms to evaluate the appropriateness of the intervention and failed to include a detailed description of the patient's physical and mental status assessments and any environmental factors that may have contributed to the situation at the time of the intervention for 2 of 3 (Patient #1 and #3) patient's with restraints.

The findings included:

1. Review of the hospital's Restraint/Seclusion policy revealed, "...The Registered Nurse notifies the patient's family, significant other or parent/legal guardian as applicable as soon as possible and documents the notification in the patient's medical record..."

2. Review of the hospital's Restraint/Seclusion Post Intervention form reveal staff documents Termination/Post Interventions such as medication/chemical restraint, medication/chemical administration time, type of restraint, if patient was in seclusion document the time in and time out of seclusion with the total time of the intervention, behavior/psychological status at termination, physical status at termination, any complaints of injury or pain associated with interventions, notification of the parent/family member, notification of the attending physician, the name of the attending physician the date and time the physician was notified.

3. Medical record review for Patient #1 revealed an admission date of 3/19/2021. Patient #1 was admitted voluntarily for Medically Assisted Detoxification from Alcohol and Opioids.

Review of the Medication Administration Record (MAR) dated 3/20/2021 at 10:48 PM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 milligrams (mg) Intramuscular (IM) and Lorazepam (Ativan) 2 mg IM for Medication/Chemical Restraint.

The hospital's Nursing Progress Notes dated 3/20/2021 at 11:08 PM, revealed Nurse #5 documented medications were administered because Patient #1 was "... argumentative and manipulative and would not be directed away from nurse's station. He demanded a cigarette and demanded to go outside...Supervisor was contacted and talked repeatedly with patient..."

There was no documentation of Restraint/Seclusion Post Intervention form was completed for the behavior and intervention on 3/20/2021.

Review of the MAR dated 3/21/2020 at 10:11 AM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 mg IM and Diphenhydramine (Benadryl) 50 mg IM for Medication/Chemical Restraint.

Review of the hospital's Nursing Progress Notes dated 3/21/2021 at 10:23 AM revealed Nurse #6 documented medications were administered because Patient #1 was "...agitated and verbally aggressive. He is paranoid and delusional, thinking someone was going to steal a bottle of alcohol from his room...Received order for chemical restraint due to agitation..."

There was no documentation a Restraint/Seclusion Post Intervention form was completed for the behavior and intervention on 3/21/2021.

In a telephone interview on 4/5/2021 at 11:00 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation a Restraint/Seclusion Post Intervention form was completed for Patient #1 for 3/20/2021 and 3/21/2021.

4. Medical record review for Patient #3 revealed an admission date of 1/4/2021 with a diagnosis of schizoaffective disorders.

Review of the hospital's Restraint/Seclusion form dated 1/11/2021 at 11:05 AM revealed Nurse #9 documented, "...Reason for intervention: imminent danger to others...patient yelling very loud and threatening staff and has been throwing objects from the desk..."

Review of the MAR dated 1/11/2021 at 11:06 AM revealed Patient #3 was administered Ziprasidone (Geodon) 20 milligrams IM and Lorazepam (Ativan) 2 milligrams IM for Medication/Chemical Restraint.

There was no documentation a Restraint/Seclusion Post Intervention form was completed for the behavior and intervention 1/11/2021.

In a telephone interview on 4/5/2021 at 11:00 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation a Restraint/Seclusion Post Intervention form was completed for Patient #3 for 3/21/2021.

Based on hospital documents, medical record review and interview the facility failed to identify and document the patient's condition or symptoms that warranted the use of restraints and failed to document the criteria for release of restraints for 1 of 3 (Patient #1) patient's with restraints.

The findings included:

1. Review of the hospital's Restraint/Seclusion Intervention form reveal staff documents the following: Reason for intervention MUST BE IMMINENT DANGER: check all that apply, Describe specific behavior exhibited, Were less restrictive interventions attempted, Less restrictive intervention interventions attempted, Criteria for release, Patient informed of criteria for release, Any medical conditions/physical disabilities/abuse issues that would impact use to restraint/seclusion use?

2. Medical record review for Patient #1 revealed an admission date of 3/19/2021. Patient #1 was admitted voluntarily for Medically Assisted Detoxification from Alcohol and Opioids.

Review of the Medication Administration Record (MAR) dated 3/20/2021 at 10:48 PM, revealed Patient #1 was administered Ziprasidone (Geodon) 20 milligrams (mg) Intramuscular (IM) and Lorazepam (Ativan) 2 mg IM for Medication/Chemical Restraint

Review of the hospital's Nursing Progress Notes dated 3/20/2021 at 11:08 PM, revealed Nurse #5 documented, "...argumentative and manipulative and would not be directed away from nurse's station. He demanded a cigarette and demanded to go outside...Supervisor was contacted and talked repeatedly with patient..."

There was no documentation a Restraint/Seclusion Intervention form was completed that revealed the reason for the intervention was imminent danger.

Review of the MAR dated 3/21/2020 at 10:11 AM, Patient #1 was administered Ziprasidone (Geodon) 20 mg IM and Diphenhydramine (Benadryl) 50 mg injectable as a now order for agitation.

Review of the hospital's Nursing Progress Notes dated 3/21/2021 at 10:23 AM, revealed RN #6 documented medications were administered because the "...patient is agitated and verbally aggressive. He is paranoid and delusional, thinking someone was going to steal a bottle of alcohol from his room...Received order for chemical restraint due to agitation..."

There was no documentation a Restraint/Seclusion Intervention form was completed that revealed the reason for the intervention was imminent danger.

3. In a telephone interview on 4/5/2021 at 11:00 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation a Restraint/Seclusion Intervention form was completed for Patient #1 for interventions for behaviors on 3/20/2021 and 3/21/2021.

Based on policy review, medical record review and interview the hospital failed to document the detailed assessment of the patient's response to the intervention(s) used including the rationale for the restraint for 1 of 3 (Patient #3) patient's with restraints.

The findings included:

1. Review of the hospital's Restraint/Seclusion policy revealed, "...The Registered Nurse demonstrates through his/her documentation in the patient's medical record the restraints/seclusion is the least restrictive intervention that protects the patient's safety and the utilization is based on an individualized patient assessment...documents patients' response to the intervention used, including rationale for continued use of intervention. Ensures the Restraint/Seclusion Patient Debriefing Form is completed within 24 hours of patient release from restraint/seclusion..."

2. Review of the Restraint/Seclusion Patient Debriefing form revealed staff documents on the form as part of the medical record the date and time of debriefing, family involved in debriefing, staff involved in debriefing, patient's perception of events/triggers leading to the intervention, patient's description of what happened to cause behaviors, patients perception of anything that could have been done differently, if patient feel his/her well-being, psychological comfort and right to privacy were maintained, any trauma experienced by patient, and strategies to prevent repeat use of intervention and/or to address factors contributing to incident.

3. Medical record review for Patient #3 revealed an admission date of 1/4/2021 with a diagnosis of schizoaffective disorders.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/5/2021 at 10:07 PM revealed Nurse #3 documented, "...Reason for intervention: Imminent danger to self and imminent danger to others ...Pt [patient] psychotic, Patient is speaking loudly in a bizarre language patient...came out of her bed, coming at staff, swinging patient attempted to hit numerous staff multiple times..."

Patient #3 was placed in a Physical Hold from 10:07 PM to 10:09 PM for a total of 2 minutes for a total of 2 minutes and was administered Medication/Chemical Restraint.

Review of the Medication Administration Record (MAR) dated 1/5/2021 at 10:12 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 milligram (mg) Intramuscular (IM) and Lorazepam (Ativan) 2 mg IM on 1/5/2021 at 10:12 PM as a Medication/Chemical Restraint.

There was no documentation a debriefing was conducted with Patient #3 that included the patient's perceptions of events/triggers leading to the interviention, the patient's description of what caused the behaviors, what could have been done differently, maintaining well-being, comfort and privacy during the intervention, any untoward outcomes and strategies to prevent the repeat use of the intervention for 1/5/2021.

Review of the MAR dated 1/8/2021 at 8:59 PM, revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/8/2021 at 9:00 PM, revealed Nurse #7 documented, "...Reason for intervention: imminent danger to self an imminent danger to others...patient verbally and physically aggressive towards staff - forcefully pushed a chair into the wall slamming doors, tore a plate off the wall and threw it into the nurses station, kicked the dayroom door open as another patient was about to enter the door..."

There was no documentation a debriefing was conducted with Patient #3 that included the patient's perceptions of events/triggers leading to the interviention, the patient's description of what caused the behaviors, what could have been done differently, maintaining well-being, comfort and privacy during the intervention, any untoward outcomes and strategies to prevent the repeat use of the intervention for 1/8/2021.

Review of the MAR dated 1/9/2021 at 7:29 PM revealed Patient #3 was administered Lorazepam (Ativan) 2 mg IM, Diphenhydramine (Benadryl) 50 milligrams IM and Haloperidol 5 mg IM for agitation.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/9/2021 at 7:30 PM revealed Nurse #1 documented, "...pt extremely manic, running, screaming, attempted to throw a chair and slapped a MHS [Mental Health Specialist] ..."

Patient #3 was placed in a hold at 7:30 PM through 7:47 PM for a total of 17 minutes and was administered a now order for agitation.

There was no documentation a debriefing was conducted with Patient #3 that included the patient's perceptions of events/triggers leading to the interviention, the patient's description of what caused the behaviors, what could have been done differently, maintaining well-being, comfort and privacy during the intervention, any untoward outcomes and strategies to prevent the repeat use of the intervention for 1/9/2021.

The medical record documented Patient #3 was placed in a hold on 1/16/2021 beginning at 12:55 AM through 1:00 AM for a total of 5 minutes.

Review of the MAR dated 1/16/2021 at 1:03 AM revealed Patient #3 was administered Ziprasidone (Geodon) 20 mg IM and Lorazepam (Ativan) 2 mg IM.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/16/2021 at 2:46 AM revealed Nurse #8 documented, "...imminent danger to self and imminent danger to others ...pt demonstrating imminent danger to self and others ...pulled the shower curtains down, was grabbing at staff and attempting to both strike and kick them..."

There was no documentation a debriefing was conducted with Patient #3 that included the patient's perceptions of events/triggers leading to the interviention, the patient's description of what caused the behaviors, what could have been done differently, maintaining well-being, comfort and privacy during the intervention, any untoward outcomes and strategies to prevent the repeat use of the intervention for 1/16/2021.

Review of the hospital's Restraint/Seclusion Intervention form dated 1/17/2021 at 10:28 AM revealed Nurse #9 documented, "...imminent danger to others...pt threw her drink at nurse and was trying to attack nurse..."

Review of the MAR dated 1/17/2021 at 7:29 PM, revealed Patient #3 was administered Lorazepam (Ativan) 2 mg IM, Benadryl 50 milligrams IM and Haloperidol 5 mg IM.

There was no documentation Patient #3 had received patient debriefing for 1/17/2021.

4. In a telephone interview on 4/5/2021 at 11:00 AM, the Chief Operating Officer/Chief Nursing Officer verified there was no documentation a debriefing was completed that included Patient #3's perceptions of events/triggers leading to the interviention, the patient's description of what caused the behaviors, what could have been done differently, maintaining well-being, comfort and privacy during the intervention, any untoward outcomes and strategies to prevent the repeat use of the intervention that occurred on 1/5/2021, 1/8/2021, 1/9/2021, 1/16/2021 and 1/17/2021.