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Based on clinical record, policy and procedure review and interview, it was determined the Facility failed to assure chemical restraint was used only as a result of failure of less restrictive interventions for 1 (#14) of 5 (#9, #10, #13 and #14) inpatient clinical records reviewed that had been restrained. It could not be assured the least restrictive interventions were implemented to protect patient #14 or others from harm prior to the use of chemical restraint. The failed practice affected Patient #14 and was likely to affect any patient who was restrained. The findings were:

A. Patient #14 was admitted to the Facility on 11/03/14. Clinical record review revealed a physician order for chemical restraint on 11/04/14 at 1420. Documentation revealed Zyprexa and Benadryl were administered IM (intramuscularly) at 1425 on 11/04/14.

B. The form "Emergency Intervention Record" was reviewed and the least restrictive measure documented was "Therapeutic De-escalation - pt was playing with ball" Physical exercise and verbal interaction was described as "refused". The de-briefing sections listed "Could anything have been done differently: Take patient off Unit where there was less stimulation if enough staff was available." The strategies to prevent use of intervention and/or to address factors contributing to incident were "remove patient to area with less stimulation earlier".

C. Review of Policy for "Emergency Interventions and De-Briefing procedures" included the statement "(Facility named) philosophy is to use the least restrictive emergency intervention procedure possible while ensuring the safety of the patient." "Less restrictive measures", as defined by this policy, included "Measures which modify the environment, enhance interpersonal interaction".

D. The Director of Nursing was interviewed on 11/07/14 at 1550 regarding the nursing entry in the debriefing that cited "if enough staff was available" and documentation of the chemical restraint for Patient #14. The Director of Nursing stated the restraint "could have been at the change of shift" and confirmed the content of the documentation.

Based on clinical record, policy and procedure review and interview, it was determined the Facility failed to assure the treatment plan of care was updated to include the use of chemical and physical restraint for 1 (#12) of 5 (#9, #10, #12, #13 and #14) inpatient clinical records reviewed that had been restrained. Failure to modify the Patient's plan of care to include the restraint use did not assure the plan of care reflected the change in the patient's assessment. The failed practice affected patient #12 and likely to affect any patient who was restrained. The findings were:

A. Patient #12 was admitted to the Facility on 10/30/14. Clinical record review revealed a physician order for Physical and Chemical Restraint on 11/03/14 at 1825. Documentation revealed Patient #12 was in a physical hold for two minutes and the medications Thorazine and Benadryl were administered IM (intramuscularly).

B. The form "Treatment Plan Modification Due to Restraint/Seclusion Patient Care Monitoring" was noted in Patient #12's clinical record. The form was blank. The instructions for use of the form stipulate "To be completed at the next staffing following the restraint seclusion".

C. Review of Policy "Emergency Interventions and Debriefing Procedures" revealed the "The need for the use of physical restraint will be added to the patient's treatment plan...".

D. The Director of Nursing confirmed on 11/07/14 at 1605 the patient treatment plan was not updated to reflect the use of chemical and physical restraints.