Current through Register Vol. 30, No. 52, December 27, 2024
A.
A mental health agency shall only use restraint or seclusion to the extent
permitted by and in compliance with this Chapter, and other applicable federal
or state law.
B. A mental health
agency shall only use restraint or seclusion:
1. To ensure the safety of the client or
another individual in an emergency safety situation;
2. After other available less restrictive
methods to control the client's behavior have been tried and were
unsuccessful;
3. Until the
emergency safety situation ceases and the client's safety and the safety of
others can be ensured, even if the restraint or seclusion order has not
expired; and
4. In a manner that:
a. Prevents physical injury to the
client,
b. Minimizes the client's
physical discomfort and mental distress, and
c. Complies with the mental health agency's
policies and procedures required in subsection (E) and with this
Section.
C. A
mental health agency shall not use restraint or seclusion as a means of
coercion, discipline, convenience, or retaliation.
D. A service provider shall at all times have
staff qualified on duty to provide:
1.
Restraint and seclusion according to this Section, and
2. The behavioral health services the mental
health agency is authorized to provide .
E. A mental health agency shall develop and
implement written policies and procedures for the use of restraint and
seclusion that are consistent with this Section and other applicable federal or
state law and include:
1. Methods of
controlling behavior that may prevent the need for restraint or
seclusion,
2. Appropriate
techniques for placing a client in each type of restraint or seclusion; used at
the mental health agency, and
3.
Immediate release of a client during an emergency.
F. A mental health agency shall develop and
implement a training program on the policies and procedures in subsection
(E).
G. A mental health agency
shall only use restraint or seclusion according to:
1. A written order given:
a. By a physician providing treatment to a
client; or
b. If a physician
providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1
psychiatric acute hospital , by a physician or a nurse practitioner;
or
ii. If the agency is licensed as
a level 1 subacute agency or a level 1 RTC , by a medical
practitioner.
2. An oral order given to a nurse by:
a. A physician providing treatment to a
client, or
b. If a physician
providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1
psychiatric acute hospital, by a physician or a nurse practitioner;
or
ii. If the agency is licensed as
a level 1 sub-acute agency or a level 1 RTC, by a medical
practitioner.
H. If a restraint or seclusion is used
according to subsection (G)(2), the individual giving the order shall, at the
time of the oral order in consultation with the nurse, determine whether, based
upon the client's current and past medical, physical and psychiatric condition,
it is clinically necessary for:
1. If the
agency is licensed as a level 1 psychiatric acute hospital, a physician to
examine the client as soon as possible and, if applicable, the physician shall
examine the client as soon as possible; or
2. If the agency is licensed as a level 1
sub-acute agency or a level 1 RTC, a medical practitioner to examine the client
as soon as possible and, if applicable, the medical practitioner shall examine
the client as soon as possible.
I. An individual who gives an order for
restraint or seclusion shall:
1. Order the
least restrictive restraint or seclusion that may resolve the client's behavior
that is creating the emergency safety situation, based upon consultation with a
staff member at the agency;
2. Be
available to the agency for consultation, at least by telephone, throughout the
period of the restraint or seclusion;
3. Include the following information on the
order:
a. The name of the individual ordering
the restraint or seclusion,
b. The
date and time that the restraint or seclusion was ordered,
c. The restraint or seclusion
ordered,
d. The criteria for
release from restraint or seclusion without an additional order, and
e. The maximum duration for the restraint or
seclusion;
4. If the
order is for mechanical restraint or seclusion, limit the order to a period of
time not to exceed three hours.
5.
If the order is for a drug used as a restraint, limit the:
a. Dosage to that necessary to achieve the
desired effect, and
b. Drug ordered
to a drug other than a time-released drug designed to be effective for more
than three hours; and
6.
If the individual ordering the use of restraint or seclusion is not a physician
providing treatment to the client:
a. After
ordering the restraint or seclusion, consult with the physician providing
treatment as soon as possible, and
b. Inform the physician providing treatment
of the client's behavior that created the emergency safety situation and
required the client to be restrained or placed in seclusion.
J. PRN orders shall not
be used for any form of restraint or seclusion.
K. If an individual has not examined the
client according to subsection (H), the following individual shall conduct a
face-to-face assessment of a client's physical and psychological well-being
within one hour after the initiation of restraint or seclusion:
1. For a behavioral health agency licensed as
a level 1 psychiatric acute hospital, a physician or nurse practitioner who is
either on-site or on-call at the time the mental health agency initiates the
restraint or seclusion; or
2. For a
behavioral health agency licensed as a level 1 RTC or a level 1 sub-acute
agency a medical practitioner or a registered nurse with at least one year of
full time behavioral health work experience, who is either on-site or on-call
at the time the mental health agency initiates the restraint or
seclusion.
L. A
face-to-face assessment of a client according to subsection (K) shall include a
determination of:
1. The client's physical and
psychological status,
2. The
client's behavior,
3. The
appropriateness of the restraint or seclusion used,
4. Whether the emergency safety situation has
passed, and
5. Any complication
resulting from the restraint or seclusion used.
M. For each restraint or seclusion of a
client, a mental health agency shall include in the client's record the order
and any renewal order for the restraint or seclusion, and shall document in the
client's record:
1. The nature of the
restraint or seclusion;
2. The
reason for the restraint or seclusion, including the facts and behaviors
justifying it;
3. The types of less
restrictive alternatives that were attempted and the reasons for the failure of
the less restrictive alternatives;
4. The name of each individual authorizing
the use of restraint or seclusion and each individual restraining or secluding
a client or monitoring a client who is in restraint or seclusion;
5. The evaluation and assessment of the need
for seclusion or restraint conducted by the individual who ordered the
restraint or seclusion;
6. The
determination and the reasons for the determination made according to
subsection (H);
7. The specific and
measurable criteria for client release from mechanical restraint or seclusion
with documentation to support that the client was notified of the release
criteria and the client's response;
8. The date and times the restraint or
seclusion actually began and ended;
9. The time and results of the face-to-face
assessment required in subsection (L);
10. For the monitoring of a client in
restraint or seclusion required by subsection (P):
a. The time of the monitoring,
b. The name of the staff member who conducted
the monitoring, and
c. The
observations made by the staff member during the monitoring; and
11. The outcome of the restraint
or seclusion.
N. If, at
any time during a seclusion or restraint, a medical practitioner or registered
nurse determines that the emergency which justified the seclusion or restraint
has subsided, or if the required documentation reflects that the criteria for
release have been met, the client shall be released and the order terminated.
The client shall be released no later than the end of the period of time
ordered for the restraint or seclusion, unless a the order for restraint or
seclusion is renewed according to subsection (Q).
O. For any client in restraint, the
individual ordering the restraint shall determine whether one-to-one
supervision is clinically necessary and shall document the determination and
the reasons for the determination in the client's record.
P. A mental health agency shall monitor a
client in restraint or seclusion as follows:
1. The client shall be personally examined at
least every 15 minutes for the purpose of ensuring the client's general comfort
and safety and determining the client's need for food, fluid, bathing, and
access to the toilet. Personal examinations shall be conducted by staff members
with documented training in the appropriate use of restraint and seclusion and
who are working under the supervision of a licensed physician, nurse
practitioner or registered nurse.
2. A registered nurse shall personally
examine the client every hour to assess the status of the client's mental and
physical condition and to ensure the client's continued well-being.
3. If the client has any medical condition
that may be adversely affected by the restraint or seclusion, the client shall
be monitored every five minutes, until the medical condition resolves, if
applicable.
4. If other clients
have access to a client being restrained or secluded or, if the individual
ordering the restraint or seclusion determines that one-to-one supervision is
clinically necessary according to subsection (O), a staff member shall
continuously supervise the client on a one-to-one basis.
5. If a mental health agency maintains a
client in a mechanical restraint, a staff member shall loosen the mechanical
restraints every 15 minutes.
6.
Nutritious meals shall not be withheld from a client who is restrained or
secluded, if mealtimes fall during the period of restraint. Staff shall
supervise all meals provided to the client while in restraint or
seclusion.
7. At least once every
two hours, a client who is restrained or secluded shall be given the
opportunity to use a toilet.
Q. An order for restraint or seclusion may be
renewed as follows:
1. For the first renewal
order, the order shall meet the requirements of subsection (G)(1) or (G)(2);
and
2. For a renewal order
subsequent to the first renewal order:
a. The
individual in (G)(1) or (G)(2) shall personally examine the client before
giving the renewal order, and
b.
The order shall not permit the continuation of the restraint or seclusion for
more than 12 consecutive hours unless the requirements of subsection (P) are
met.
R. No
restraint or seclusion shall continue for more than 12 consecutive hours
without the review and approval by the medical director or designee of the
mental health agency in consultation with the client and relevant staff to
discuss and evaluate the needs of the client. The review and approval, if any,
and the reasons justifying any continued restraint or seclusion shall be
documented in the client's record.
S. If a client requires the repeated or
continuous use of restraint or seclusion during a 24-hour period, a review
process shall be initiated immediately and shall include the client and all
relevant staff persons and clinical consultants who are available to evaluate
the need for an alternative treatment setting and the needs of the client. The
review and its findings and recommendations shall be documented in the client's
record.
T. Whenever a client is
subjected to extended or repeated orders for restraint or seclusion during a
30-day period, the medical director shall require a special meeting of the
client's clinical team according to R9-21-314 to determine whether other
treatment interventions would be useful and whether modifications of the ISP or
ITDP are required.
U. As part of a
mental health agency's quality assurance program, an audit will be conducted
and a report filed with the agency's medical director within 24 hours, or the
first working day, for every episode of the use of restraint or seclusion to
ensure that the agency's use of seclusion or restraint is in full compliance
with the rules set forth in this Article.
V. Not later than the tenth day of every
month, the program director shall prepare and file with the Administration and
the Office of Human Rights a written report describing the use of any form of
restraint or seclusion during the preceding month in the mental health agency
or by any employees of the agency. In the case of an inpatient facility, the
report shall also be filed with any patient or human rights committee for that
facility.
W. The Office of Human
Rights, and any applicable human rights committee shall review such reports to
determine if there has been any inappropriate or unlawful use of restraint or
seclusion and to determine if restraint or seclusion may be used in a more
effective or appropriate fashion.
X. If any human rights committee or the
Office of Human Rights determines that restraint or seclusion has been used in
violation of any applicable law or rule, the committee or Office may take
whatever action is appropriate, including investigating the matter itself or
referring the matter to the Administration for remedial action.
