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Based on clinical record review and interview, it was determined the Facility failed to assure orders were not written for PRN (as needed) medications to be administered at the onset of psychotic unsafe behavior or unsafe agitation in 7 (#1, #3, #4, #6-#9) of 10 (#1-#10) records. The failed practice did not assure patients did not undergo chemical restraint at the discretion of the Registered Nurse and did not assure physicians were notified of the event. This failed practice had the potential to affect all patients on the Geriatric Psychiatric Unit. Findings follow:

A. Review of the Psychiatric Admission Orders for Patients #1, #3, #4, #6-#9 revealed Haldol 2 mg (milligram) po (by mouth) or IM (intramuscular) if refuses po, PRN (as needed) onset of psychotic unsafe behavior and repeat q (every) 2 hours if indicated, not to exceed 8 mg within 24 hours was ordered.
B. Review of the Psychiatric Admission Orders for Patients #1, #3, #4, #6-#9 revealed Ativan 0.5 mg po, or IM if refuses po, PRN onset of unsafe agitation and repeat q 2 hours if indicated, not to exceed 1.5 mg in 24 hours was ordered.
C. Review of Medication Administration Record for Patient #1 revealed Haloperidol (Haldol) 2 mg was administered on 03/11/14 at 2350 and on 03/12/13 at 1425. Ativan 2 mg was administered on 03/12/13 at 1425. Review of Shift Assessment dated 03/11/14 at 2350 revealed Patient #1 was medicated with Haldol 2 mg po for behavior. Review of Shift Assessment dated 03/12/13 at 1430 revealed became combative, pushing and hitting staff. Unable to redirect. Haldol 2 mg and Ativan 0.5 mg administered. There was no evidence the physician was notified.
D. Review of Medication Administration Record for Patient #3 revealed Haloperidol 2 mg and Ativan 0.5 mg were administered 05/03/14 at 1800. Review of Shift Assessment dated 05/03/14 at 1756 revealed pt anxious, irritable earlier, cursing at staff, pt medicated with Ativan 0.5 mg and Haldol 2 mg. There was no evidence the physician was notified.
E. Review of the Medication Administration Record for Patient #6 revealed Ativan 2 mg was administered 06/12/14 at 0100. Review of List Patient Notes for Patient #6 revealed Pt was up in hall and was agitated. There was no evidence the physician was notified.
F. Review of the Medication Administration Record for Patient #9 revealed Haloperidol 2 mg was administered 06/15/14 at 2340. Review of List Patient Notes for Patient #9 revealed Haldol 2 mg given for hallucinations. There was no evidence the physician was notified.
G. Review of the Medication Administration Records for Patients #4, #7, and #8 did not have evidence Haldol or Ativan was administered.
H. Findings were confirmed with the Nurse Manager for the Geriatric Psychiatric Unit on 06/13/14 at 1245.