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Based on record review, and staff interview the hospital failed to ensure medications used to restrict or manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition for 2 of 13 (#3, #13) patient ' s reviewed for restraints. Findings:

1. Closed record review on 6/30/2015 at 9:10 a.m. revealed patient #3 was admitted to the hospital on 3/26/2015 with Diagnoses of Dementia, Alcohol Abuse, Pneumonia, Respiratory Failure, Subdural Hematoma, and CVA (Cerebral Vascular Accident) and discharged on 5/1/2015.

Review of the Medication Reconciliation Form dated 3/26/2015 confirmed orders for Ativan 2mg/ml 2mg IVP (IV Push) every 2 hours PRN (as Needed) for severe anxiety, and Ativan 2mg/ml 1mg IVP every 4 hours PRN for moderate anxiety. There were no specific guidelines to determine severe or moderate anxiety.

Review of the Daily Nursing Re-Assessment 12 Hour Shift document dated 3/28/2015 revealed entry at 10:00 p.m. Ativan 2mg IV for agitation per SF18RN (Registered Nurse). There is no documentation noted to assess the patient ' s behaviors prior to the medication or any alternate interventions attempted before the medication was given.

2. Record review on 6/23/2015 at 2:30 p.m. revealed patient #13 was admitted to the hospital on 6/23/2015 with diagnoses of Bibasilar Pneumonia, Atrial Fib, Hypertension, Osteoarthritis, and Dementia.

Review of the Physicians Orders dated 6/29/2015 revealed order for Ativan 1mg IVP now and every 6 hours PRN agitation.

Review of the Daily Nursing Re-Assessment 12 Hour Shift document dated 6/29/2015 revealed entry at 7:30 p.m. of the patient agitated, attempting to hit and bite at staff. At 8:30 p.m. entry documented remains agitated, new order received for Ativan 1mg IVP per SF20RN. There is no documentation noted to assess the patient ' s behaviors prior to the medication or any alternate interventions attempted before the medication was given.

Telephone interview on 7/1/2015 at 8:45 a.m. with SF20RN confirmed that she did assess the patient before giving the Ativan but did not document her findings in the nurse ' s notes.

Review of the facility policy titled Restraints; revised April 2015 revealed that the facility did not have a policy that included the use for chemical restraints and procedures that reflect current standards of practice regarding safe and appropriate use of chemical restraints.

Interview on 6/30/2015 at 3:00 p.m. with SF2RN confirmed that the Charge Nurse or Registered Nurse should be documenting an assessment prior to administering any PRN medications for behavior.

Based on interview and record review, the hospital failed to ensure the Restraint policy included the use of chemical restraints and the procedures that reflect current standards of practice regarding safe and appropriate use of chemical restraints. Findings:

Review of the hospital policy titled Restraints, revised April 2015 revealed in part: Definition: 2. A restraint is any drug or medication when it is used as a restriction to manage the patient ' s behavior or restrict the freedom of movement and is not a standard treatment or dosage for the patient ' s condition.

Interview on 6/30/2015 at 3:00 p.m. with SF2RN confirmed that the hospital policy did not include the use of chemical restraints. SF2RN also confirmed that the staff Charge Nurse or Registered Nurse should be following the standards for practice and document an assessment, alternative measures prior to the chemical restraint, and if the medication was effective.

Interview on 7/1/2015 at 12:05 p.m. with SF1CNO confirmed that the hospitals policy for restraints did not include the use of chemical restraints.

Based on record review, and staff interview the hospital failed to ensure orders for chemical restraints were not written as a standing order or on an as needed basis (PRN) for 2 of 13 (#3, #13) records reviewed. Findings:

1. Closed record review on 6/30/2015 at 9:10 a.m. revealed patient #3 was admitted to the hospital on 3/26/2015 review of the Medication Reconciliation Form dated 3/26/2015 confirmed orders for Ativan 2mg/ml 2mg IVP (IV Push) every 2 hours PRN (as Needed) for severe anxiety, and Ativan 2mg/ml 1mg IVP every 4 hours PRN for moderate anxiety. There were no specific guidelines to determine severe or moderate anxiety.

Review of the Daily Nursing Re-Assessment 12 Hour Shift document dated 3/28/2015 revealed entry at 10:00 p.m. Ativan 2mg IV for agitation per SF18RN (Registered Nurse). On 3/29/2015 at 3:25 a.m. Ativan 2mg IVP for agitation was given, at 0850 Ativan 2mg IVP was given for agitation, and at 11:00 a.m. Ativan 2mg IVP was given for agitation per SF18RN. Further review revealed on 3/31/2015 patient #3 received Ativan 2mg IVP for agitation at 9:27 a.m., 8:15 p.m., and 11:30 p.m.

Review of the Physicians orders dated 4/1/2015 revealed order to hold all sedation and pain medications and place patient on 1:1 supervision.

2. Record review on 6/23/2015 at 2:30 p.m. revealed Physicians Orders dated 6/29/2015 revealed order for Ativan 1mg IVP now and every 6 hours PRN agitation.

Review of the Daily Nursing Re-Assessment 12 Hour Shift document dated 6/29/2015 revealed entry at 7:30 p.m. of the patient agitated, attempting to hit and bite at staff. At 8:30 p.m. entry documented remains agitated, new order received for Ativan 1mg IVP per SF20RN.

Review of the facility policy titled Restraints; revised April 2015 revealed that the facility did not have a policy that included the use for chemical restraints and procedures that reflect current standards of practice regarding safe and appropriate use of chemical restraints.

Interview on 6/30/2015 at 3:00 p.m. with SF2RN stated that she was unaware that you could not have a PRN order for chemical restraints.