Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-107 - Psychiatric Residential Treatment Facility Services
Subsection 144-101-II-107.09 - REQUIREMENTS FOR USE OF RESTRAINT AND SECLUSION

A. When the intervention is absolutely necessary to protect the member from causing serious physical harm to self or others. Restraint or seclusion must not be utilized solely to address the comfort, convenience, or anxiety of staff, or as a form of coercion, discipline, or retaliation;

B. The intervention is the least restrictive emergency safety intervention necessary to resolve the emergency safety situation after other methods have been proven ineffective or inappropriate;

C. The restraint or seclusion is performed only by staff with specific training in these interventions. These interventions are applied in a manner that is safe, proportionate, and appropriate to the severity of behavior, and the member's chronological and developmental age, size, gender, physical conditions, psychiatric conditions, medical conditions, and personal history. The restraint or seclusion must not result in harm or injury to the member and must be used only:

D. Restraint (including physical and mechanical restraints) and seclusion must not be used simultaneously; and

E. Locked seclusion is prohibited. The member may not be confined alone to any area with the door locked, barred, or held shut by staff.

F. For minor members, the Treatment Planning Team must decide and document in the Treatment Plan whether to allow restraints to be employed on a particular member in the event of an emergency safety situation and where the requirements of this section are met

A. The restraint or seclusion must be ordered by a physician or a nurse practitioner who is acting under the guidance of the team physician. When the team physician is available, only he or she may order restraint or seclusion. In the event that the provider ordering restraint or seclusion is not the treatment planning team physician, the ordering provider must consult with the member's treatment planning team physician as soon as possible and inform him or her of the emergency safety situation that required the member to be restrained or placed in seclusion and document in the member's record the date and time the team physician was consulted. The order must be the least restrictive emergency safety intervention that is most likely to be effective in resolving the emergency safety situation based on consultation with staff.

B. An order for restraint or seclusion may be given after an examination by a physician or nurse practitioner. In the event neither are available, a registered nurse, acting in consultation with and in accordance with protocol approved by the Medical Director, may conduct the examination and approve the emergency safety intervention.

C. An order for restraint or seclusion must not be written as a standing order or on an as-needed (PRN) basis. An order for restraint or seclusion may be given only during or immediately after the emergency safety situation arises.

D. The order must include:

E. Each order for restraint or seclusion must adhere to the following:

F. If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse, while the emergency safety intervention is being initiated by staff, or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted to order restraint or seclusion must verify the verbal order in a signed written form in the member's record. The physician or other licensed practitioner permitted to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention;

G. Under no circumstances may prone restraints be ordered or used. Additionally, providers must not initiate or sustain any restraint that may hinder chest and abdomen movement.

A. Monitoring of the Member During and Immediately Following Restraint

B. Monitoring of the Member During and Immediately After Seclusion

A. Within thirty (30) minutes of the initiation of the emergency safety intervention, the team physician, or nurse practitioner must conduct a face-to-face of the physical and psychological well-being of the member. If the examination is not able to occur within thirty (30) minutes, the reason why must be documented in the member's record. The examination may be in person, or by phone in consult with a registered nurse. Documentation of the physician's or nurse practitioner's examination must be entered into the member's record. When a telephonic consult occurs, the physician, or nurse practitioner must examine the member in person within the following time constraints:

B. Thereafter, the need for a member's continuation in the emergency safety intervention shall be re-evaluated every two hours by a nurse. The nurse shall examine the member in person. For a member subject to an order of seclusion, the examination may be conducted outside the seclusion area; the nurse shall note the clinical reasons for selection of the examination site. For a member subject to an order of restraint, the examination may be conducted with the member free of restraints; the nurse shall note the clinical reasons for selecting whether the member is examined in or free or restraints. The nurse shall assess the member to determine whether the intervention is absolutely necessary to protect the member from causing serious harm to self or others. If the nurse finds these conditions are still met, then the emergency safety intervention may be continued if the physician's or nurse practitioner's order has not yet lapsed. Should the member not need continued seclusion or restraint, the nurse shall release the member even if the time frame of the original order has not yet lapsed. Documentation of the nurse's examination must be entered into the member's record.

C. In addition to the above criteria, examinations conducted under this section include, but are not limited to:

A. A member in time out must never be physically prevented from leaving the time out area;

B. Time out may take place away from an activity or from other members, such as in the member's room (exclusionary), or in the area of activity of other members (inclusionary);

C. Staff must monitor the member while he or she is in time out.

A. Documentation regarding the use of restraint and seclusion must be kept within the member record; and must be completed by the end of the shift in which the intervention occurs. If the intervention does not end during the shift in which it began, documentation must be completed during the shift in which it ends. Documentation of the restraint or seclusion must include all the following:

B. If the member is a minor or has a legal guardian:

A. Within 24 hours after the use of restraint or seclusion, staff involved in an emergency safety intervention and the member must have a face to face discussion. This discussion must include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the member. Other staff may participate in the discussion when it is deemed appropriate by the facility. The member's parents or legal guardians, as applicable, must be given the opportunity to participate in the discussion, unless clinical staff have determined that participation would be detrimental to the member. The facility must conduct such discussion in a language that is understood by the member's parents or legal guardians. The discussion must provide both the member and the staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the member, or others that could prevent the future use of restraint or seclusion.

B. Within 24 hours after the use of restraint or seclusion, all staff involved (including any clinical staff involved) in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a separate debriefing session (to not include the member) that includes, at a minimum, a review and discussion of:

C. Staff must document in the member's record that both debriefing sessions took place and must include in that documentation the names and signatures of staff who were present for the debriefing, the names of staff that were excused from the debriefing (and the reason for the non-presence of the staff), and any changes to the member's treatment plan that result from the debriefings.

A. Staff must immediately obtain medical treatment from qualified medical personnel for a member injured as a result of use of a restraint or seclusion.

B. The PRTF must have affiliations or written transfer agreements in effect with one or more hospitals enrolled with MaineCare that reasonably ensure that:

C. Staff must document in the member's record all injuries that occur as a result of the use of restraints or seclusion, including injuries to staff resulting from the intervention.

D. Staff involved in the use of restraint or seclusion that results in injury to a member or staff must meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.