Current through Register Vol. 47, No. 6, September 18, 2024
Physician's orders are required to use any kind of mechanical
restraints or seclusion. (I, II, III) Restraints are defined as the
following:
1. Type I is physical
restraint which uses equipment to promote the safety of the individual. It is
not applied directly to a person. Examples: divided doors and side
rails.
2. Type II is mechanical
restraint applied to someone's body. A device is applied to the body to promote
safety of the individual. Examples: vests or soft tie devices, hand socks,
geriatric chairs.
3. Type III is
mechanical restraint applied to any part of the body which inhibits only the
movement of that part of the body. Examples: wrist, ankle or leg restraints and
waist straps.
(1) Temporary restraint of
residents shall be used only to prevent injury to the resident or to others.
(I, II)
(2) Temporary seclusion may
be used:
a. To prevent injury to the resident
or to others; (I, II)
b. To prevent
serious disruption to the treatment program of other residents; (I,
II)
c. To decrease stimulation
which contributes to psychotic behavior; (I, II) and
d. When other interventions have failed. (I,
II)
Restraint and seclusion shall not be used for punishment, for
the convenience of staff, or as a substitution for supervision of program.
Seclusion shall be used only in a department approved seclusion room. (I,
II)
(3)
Restraints shall be stored in an area easily accessible to staff. (I, II, III)
Type II and Type III restraints shall be specifically designed, manufactured,
and customarily used to restrain individuals hospitalized in licensed
psychiatric hospitals. Metal and plastic handcuffs, rope and makeshift devices
are prohibited. (I, II)
(4) Under
no circumstances shall a resident be allowed to participate in the restraint of
another resident. (I, II)
(5) There
shall be written policies that address the basic assumption and philosophy that
govern the use of seclusion and physical and mechanical restraint. These shall:
a. Define the uses of seclusion and
mechanical restraints; (III)
b.
Designate staff who may authorize its use; (III)
c. Identify procedures to follow when
implementing the policy which shall include provisions to ensure privacy and
safety for restrained residents; (III) and
d. A written plan for treatment following the
use of restraint or seclusion.
(6) The physician and QMHP shall be notified
immediately of the resident's need for placement in restraint or seclusion. An
order for restraint or seclusion identifying the type, purpose and duration of
use shall be obtained from the physician. If the resident is in seclusion
longer than four hours, the physician and qualified mental health professional
shall visit and evaluate the resident before the seclusion order is continued.
If the resident is in restraint for two hours, the physician shall be called
before the restraint order can be continued. If the resident is in restraint
longer than four hours, the physician and QMHP shall visit and evaluate the
resident before a restraint order is continued. Standing or PRN orders for
seclusion or restraint are prohibited. (I, II)
(7) If a resident is restrained with Type II
or Type III restraints for 6 hours or secluded for 12 hours in a 24-hour
period; or if the resident is secluded or restrained with Type II or Type III
restraints for any amount of time in three consecutive 24-hour periods, the
physician and QMHP shall visit the resident and assess the resident's need for
a higher level of care. If the need for restraint or seclusion continues, the
resident shall be transferred to an acute level of care. (I, II)
(8) During any period of mechanical restraint
or seclusion, the facility shall provide for the emotional and physical needs
of the resident. (I, II)
(9) The
resident shall be informed of the reason for seclusion and restraint and
conditions for release. The resident's guardian shall be notified when Type II
or Type III restraints or seclusion is used. The facility shall also notify the
resident's family or other significant person if the resident has previously
signed a form granting consent to do so. (I, II, III)
(10) Each resident's record shall contain all
information about restraints or seclusion. The administrator shall maintain a
daily record of seclusion use. This record shall be available for review by the
department. (II, III)
Documentation of each incident of restraint or seclusion
shall include at least:
a. Clinical
assessment before the resident is secluded or restrained; (I, II)
b. Circumstances that led to seclusion or
restraint; (I, II)
c. Explanation
of less restrictive measures used before restraint or seclusion; (I,
II)
d. Physician's order; (I,
II)
e. Visual observation of the
resident every 15 minutes, or more frequently if needed, to monitor general
well-being including respirations, circulation, positioning and alertness as
indicated; (I, II)
f. Description
of the resident's activity at the time of observation to include verbal
exchange and behavior; (I, II)
g.
Description of safety procedures taken (removal of dangerous objects, etc.);
(I, II)
h. Vital signs, including
blood pressure, pulse and respiration unless contraindicated by resident
behavior and reasons documented; (I, II)
i. Release of each mechanical restraint and
exercise and massage every two hours; (I, II, III) / Record of intake of food
and fluid; (I, II, III)
j. Number of
hours and minutes in seclusion. (II, III)
k. Use of toilet; (II, III) and
(11) The facility shall educate
staff on restraint and seclusion theory and techniques. The training shall be
conducted by people with experience and documented education in the appropriate
use of restraint and seclusion. (II, III)
a.
The facility shall keep a record of the training for review by the department
and shall include attendance. (II, III)
b. Only staff who have documented training in
restraint and seclusion theory and techniques shall be authorized to assist
with seclusion or restraint of a resident. (I, II, III)
(12) The facility shall maintain a record of
the hours and minutes of each type of restraint and seclusion used on a monthly
basis.