Nevada Administrative Code
Chapter 449 - Medical and Other Related Facilities
HOSPITALS
Policies and Procedures for Operation of Hospital
Section 449.3628 - Protection of patients; use of physical restraints

1. A governing body shall develop and carry out policies and procedures that prevent and prohibit:

2. The governing body shall develop and carry out policies and procedures that prevent and prohibit neglect and misappropriation of the personal property of a patient.

3. The governing body shall develop policies and procedures for the identification and investigation of neglect and abuse of patients.

4. The governing body shall develop and carry out organizational policies and procedures that limit the use of physical restraints on patients to only those situations in which the use of physical restraints is appropriate and for which there is adequate clinical justification.

5. The governing body shall ensure that the use of any physical restraints on a patient is initiated only pursuant to a physician's order or protocols approved by the medical staff and the hospital administration.

6. If the use of physical restraints is permitted pursuant to approved protocols, the approved protocols must include:

7. Organizational policies and procedures, protocols, physician's orders and the individual needs of a patient must be used to establish the frequency, nature and extent of monitoring of a patient upon whom physical restraints are being used.

8. The hospital shall have a process for quality improvement to identify appropriate opportunities for reducing the use of physical restraints. The process for quality improvement must include areas for measurement and assessment to identify opportunities to reduce the risks associated with the use of physical restraints through the introduction of preventive strategies, innovative alternatives to the use of physical restraints and improvements to the process of using physical restraints.