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Based on record review and interview, the facility failed to ensure that orders for the use of seclusion were never written as an "as needed" order. This failure resulted in 1 of 3 pateints (Patient #1) having an order for seclusion written "seclusion if necessary."

Findings included:

Record review of the Physician Orders for Patient #1 dated 12/1/2019 at 10:03pm showed: "Seclusion if necessary. Thorazine 50mg by mouth or intramuscular times one dose now for agitation/aggression." This was a telephone order documented by Staff K (RN) from Staff B (MD).

In an interview with Staff C and Staff E on 2/6/2020 at 12:00pm, they stated that orders are never be written as PRN or as needed.

Record review of policy #200.40, "Restraint/Seclusion" reviewed 9/15/2019 showed: "C. Physician Orders ... Restraint or seclusion shall be used in emergency situations and requires an order from a physician ... The physician ... orders are not written as standing or PRN [as needed] orders. Telephone orders for restraint/seclusion may be received and recorded by an RN."

Based on interview and record review, the facility failed to perform a required face-to-face post-restraint assessment on 1 of 4 current patients (Pt #2).

Findings included:

Record review of facility policy titled "RESTRAINT/SECLUSION, PATIENT CARE PROCEDURES", POLICY #200.40, effective 10/21/14, page 6, E, stated Face-to-Face evaluation by the physician or trained RN was to be performed within 1 hour following the initiation of the restraint/seclusion. The evaluation would be documented in the medical record and include the date and time of evaluation, an assessment of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, as well as review and assessment of the patient's history, drugs and medications, most recent lab work, and the need to continue of terminate the restraint/seclusion.

Record review on the morning of 2/5/20 of Patient #2's clinical records showed there was an order from Dr. #A, dated 1/31/20 at 7:50 AM to administer the emergency medications Haldol 5 milligrams (mg), Ativan 1 mg, and Benadryl 50 mg intramuscular (IM) for psychosis. Progress notes revealed the patient had been aggressive with staff and peers, was restrained, given the emergency medications ordered, and secluded.

Further record review failed to show any documentation regarding the restraint/seclusion, including the required face-to-face 1-hour post-restraint assessment.

In an interview on 2/5/20 at 12:45 PM, PI Director #C stated that there were no incident reports generated which would have alerted him to review the restraint/seclusion. He added that there no proof the 1 hour Face-To-Face post restraint/seclusion assessment had been done, and more re-education of staff would be conducted.