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Based on review of clinical records and interview, it was determined the Facility failed to assure chemical restraints were not ordered PRN (as needed) for 1 (#5) of 10 (#1-#10) patient records reviewed. Failure to assure chemical restraints were not ordered PRN did not assure patient's behavior was managed by physician order and not at the discretion or convenience of the nurse. The findings were:

A. Clinical record review on 03/31/15 revealed Patient #5 was admitted on 03/09/15. Review of the History and Physical dated 03/09/15 revealed the following diagnosis: Late effects CVA (cerebrovascular accident) with Right hemiparesis, Dysphagia, Expressive Aphasia, A-Fib (atrial fibrillation), CAD (coronary artery disease), CKD (chronic kidney disease), HTN (hypertension), Anemia, and Anxiety. The history and physical documented Patient #5 as "unable to follow commands" and "unable to understand speech". The patient had orders for Speech Therapy, Occupational Therapy and Physical Therapy.

B. Physician order review revealed: 03/16/15 at 1155, Seroquel 12.5 milligrams by mouth twice a day as needed for "agitation". On 03/23/15 at 1400, Seroquel 25 mg (milligrams) by mouth one time "now".

C. Review of the Nursing Narrative Comments revealed Seroquel was administered as follows:
03/19/15 at 1656: "Seroquel 12.5 mg P.O. given for agitation displayed after family members x 2 left building after brief visit with patient. 1720 Patient calmer. Resting in bed at this time. SR (arrow up) x 4."
03/21/15 at 1350: "Patient agitated, treated with Seroquel, will reassess."
03/23/15 at 1210: "Pt. (patient) agitated at this time PRN (as needed) Seroquel given at this time. Will continue to monitor."
03/23/15 at 1345: "Family voiced concern over pt. (increased) agitation at this time. Nurse spoke with (Named) about Pt. N.O. (new order) given for Seroquel 25 mg po x 1 now."

D. Review of the Medication Administration Record (MAR) revealed a start date of 03/16/15 for (Quetiapine), Seroquel 12.5 mg po, 0.5 tab x 25 mg/each PRN twice a day. "Give for agitation". Seroquel was documented on the MAR as administered at the following dates and times: 03/16/15 at 1224; 03/17/15 at 1218; 03/18/15 at 1320; 03/19/15 at 1656; 03/21/15 at 1350 and 03/23/15 at 1210. A one-time Seroquel 25 mg P.O. was documented as administered on 03/23/15 at 1410.

E. A "Neuropsych Consult Note" dated 03/26/15, was reviewed and included the following statements by the physician: "Patient understanding very frustrated, confused, and discouraged 2o to CVA. Patient w (with) aphasia 2o to Left MCA CVA (middle cerebral artery). Patient poorly oriented used multiple choice to compensate for aphasia. Immediate memory severely impaired; delayed memory recall - severely impaired, attention processing severely impaired and visual spatial is moderately impaired. The impressions were "Patient with left MCA CVA with anoc. R. hemiparesis. Patient is 7 weeks post major stroke. Even with multiple choice format to compensate for aphasia patient demonstrated confusion. She is understandably frustrated and discouraged 2o to CVA." The recommendations section APN colleagues, "Patient on Buspar and Seroquel - may consider (arrow up) increasing Buspar. Aricept and Namenda both on board - very appropriate."

F. Facility policy and procedure "Use of Restraints in Rehabilitation Hospitals" was reviewed and included the statement (1.g) "The following are not considered restraints: Medication used as part of a patient's standard medical or psychiatric treatment and are administered within the pharmaceutical parameters and Manufacturer's guidelines."

G. Registered Nurse #1 confirmed the clinical record findings and medication administration findings on 03/31/15 at 1000.