New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 526 - QUALITY OF CARE AND TREATMENT
Section 526.4 - Restraint and seclusion
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 526.4
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Definitions.
For purposes of this section, the following terms are defined:
(1)
Behavior
management plan means a document that identifies a patient's
individual preferences and behaviors related to behavioral management
interventions, (e.g., an individual calming plan, an
individual crisis prevention plan, or a personal safety plan).
(2)
Commissioner means the
Commissioner of Mental Health.
(3)
Drug used as a restraint means a drug or medication when it is
used as a restriction to manage the patient's behavior or restrict the
patient's freedom of movement and is not a standard treatment or dosage for a
patient's medical or psychiatric condition, or as otherwise defined in Federal
regulations of the Centers for Medicare and Medicaid Services.
(4)
Emergency means a
situation in which a patient's behavior creates an imminent threat of serious
injury to the patient or another person, where there is the present ability to
effect such harm. For purposes of this section, a threat to property shall not
be considered an emergency.
(5)
Facility means a hospital as defined in section 1.03 of the Mental Hygiene Law, and shall
include the hospital sub-class of residential treatment facilities for children
and youth, as defined in such section.
(6)
Manual restraint means
the use of a manual or physical method to restrict a person's freedom of
movement or normal access to his or her body. The term manual
restraint means and includes the term physical
restraint.
(7)
Mechanical restraint means an apparatus which restricts a
patient's movement of the head, limbs, or body, and which the patient is unable
to remove, provided, however, this term may also apply to an apparatus not
normally used for this purpose, such as a bed rail or bed sheet, if the patient
is not able to release the mechanism.
(8)
Mechanical support means
a device intended to keep the person in a safe or comfortable position, which
the patient can remove at will, or to provide the stability necessary for
therapeutic and preventive measures such as immobilization of fractures,
administration of intravenous solutions or other medically necessary
procedures.
(9)
Nurse means a registered professional nurse employed by, or
rendering services in, a facility certified by the Office of Mental Health, who
is currently licensed pursuant to article 139 of the Education Law.
(10)
Office means the New
York State Office of Mental Health.
(11)
Physical escort means
the use of a light grasp to escort a patient to a desired location, which the
patient can easily remove or avoid.
(12)
Restraint means any
manual method, mechanical device, or pharmacologic measure which immobilizes or
reduces the ability of an individual to freely move his or her arms, legs,
body, or head. For purposes of this Part, restraint means and
includes manual restraint, drug used as a restraint, and mechanical
restraint.
(13)
Seclusion means the involuntary confinement of a patient in a
room or area where the patient is prevented from leaving (or where the patient
reasonably believes that he or she will be prevented from leaving), with no
ability to meaningfully interact with other patients or staff, provided,
however, it shall not mean confinement on a locked unit or ward where a patient
is with others.
(14)
Time
out means a voluntary procedure used to assist a patient in regaining
emotional control by providing access to a quiet area or unlocked quiet room
away from his/her immediate environment.
(b) General principles.
(1) Purpose of intervention.
(i) Management of violent or self-destructive
behavior. Restraint and seclusion are safety interventions which may be used
for purposes of managing violent or self-destructive behavior only in emergency
situations if such intervention is necessary to avoid imminent, serious injury
to the patient or others, and less restrictive interventions have been utilized
and determined to be ineffective, or in rare instances where the patient's
dangerousness is of such immediacy that less restrictive interventions cannot
be safely employed. Such restraint or seclusion shall only be used for the
duration of the emergency.
(ii)
Medical or post-surgical care. To ensure good medical outcomes, a mechanical
restraint may be used to limit mobility or temporarily immobilize a patient in
relation to a medical, post-surgical, or dental procedure.
(2) Restraint or seclusion for any purpose
shall never be utilized as punishment, for the convenience of staff, to
substitute for inadequate staffing, or as a substitute for treatment
programs.
(3) In choosing the form
of intervention for any purpose, staff shall utilize the least restrictive type
which is appropriate and effective under the circumstances.
(4) A restraint does not include mechanical
supports, physical escort, or the physical holding of a patient for the purpose
of conducting routine physical examinations or tests (to which he or she does
not object).
(5) Seclusion shall
not be used with persons with a sole diagnosis of a developmental disability.
Seclusion may be used for persons with a dual diagnosis of mental illness and a
developmental disability, provided that such persons are under one-to-one
constant visual observation while in seclusion, and all other provisions of
this section governing the utilization of seclusion are met.
(c) Restraint and seclusion to manage violent or self-destructive behavior.
(1) General conditions for use.
(i) The use of restraint and seclusion to
manage violent or self-destructive behavior in a facility must be in accordance
with the written order of a physician and selected only when:
(a) less restrictive measures (including any
such interventions that have been identified in a patient's behavior management
plan), have been utilized and found to be ineffective to protect the patient
from seriously injuring self or others; or
(b) in rare instances where the patient's
dangerousness is of such immediacy that less restrictive interventions cannot
be safely employed.
(ii)
Utilization of seclusion or restraint to manage violent or self-destructive
behavior shall not be based solely on a patient's seclusion or restraint
history or on a history of dangerous behavior.
(iii) Mechanical restraint. The only
permissible forms of mechanical restraint shall be those devices which have
been authorized by the commissioner.
(2) Simultaneous use. A mechanical restraint
and seclusion shall not be used simultaneously.
(3) Limitations. The following restraint
techniques shall not be utilized in any facility subject to the provisions of
this Part:
(i) any technique that obstructs a
patient's respiratory airway or impairs his or her breathing or respiratory
capacity, including techniques in which a staff member places pressure on a
patient's back or places his or her body weight against the patient's torso or
back;
(ii) a technique that
utilizes a pillow, blanket, or other item to cover the patient's
face;
(iii) use of any technique on
a patient who has a known medical or physical condition where there is reason
to believe that use of such technique would endanger the person's life or
significantly exacerbate the person's medical condition; or
(iv) restraint in a prone (face down)
position.
(4) Patient
behavior management history assessment. A facility shall conduct an initial
patient behavior management history assessment of each patient upon admission
to the facility, or as soon thereafter as possible, based upon readily
available or obtainable information, and shall develop a behavior management
plan.
(5) Orders for the use of
restraint or seclusion.
(i) General. Orders
for the use of restraint or seclusion:
(a)
must be in writing and signed by a physician;
(b) must be based on a personal, face-to-face
examination by the physician which includes both a physical and psychological
examination of the patient;
(c)
must be implemented in the least restrictive manner possible, such that the
risks associated with the use of the restraint and/or seclusion are outweighed
by the risk of not using it, including consideration of alternative
interventions;
(d) must be
implemented in accordance with safe, appropriate restraining techniques, as
approved by the office;
(e) must be
ended at the earliest possible time; and
(f) shall never be written as a standing
order or on an as-needed basis (PRN order).
(ii) Duration. Each written order for
restraint or seclusion shall be no more than: 4 hours for adults; 1 hour for
children and adolescents ages 9 to 17; and 30 minutes for children under 9;
provided, however:
(a) with respect to manual
restraint, orders must be limited in duration to 30 minutes for patients of any
age, provided, however, the use of manual restraint must be limited to the
duration of the emergency situation, regardless of the length of the order;
and
(b) if an episode of mechanical
restraint or seclusion has exceeded 2 hours for adults, 1 hour for children and
adolescents ages 9 to 17, or 30 minutes for children under age 9, and it is
expected that restraint or seclusion will be required beyond such time periods,
the facility medical director or director of psychiatry (or his/her designee)
shall be notified and consulted.
(iii) Justification. Each written order for
restraint and seclusion must include documentation supporting its reasons for
issuance.
(iv) Renewals. If
restraints or seclusion are discontinued prior to the expiration of the
original order, a new order must be obtained prior to reinitiating seclusion or
reapplying the restraints; and, provided further, after the original order
expires, a physician must see and assess the patient, in person, before issuing
a new order.
(6)
Initiation in the absence of a physician.
(i)
Restraint or seclusion may be initiated in the absence of a physician's written
order only in situations where the patient presents an immediate danger to self
or others and a physician is not immediately available to examine the patient,
provided, however, that the restraint or seclusion must be initiated at the
direction of a registered professional nurse, nurse practitioner, or
physician's assistant who has been authorized by the facility, based on
credentials and competencies, to approve the use of restraint or seclusion in
the absence of a physician or, in the absence of the nurse, nurse practitioner,
or physician's assistant, at the direction of the senior staff member
authorized in facility policy to initiate restraint or seclusion in the event
of such absence. A written order by a physician must still be obtained to
authorize the intervention, in accordance with the procedures set forth in
Mental Hygiene Law section 33.04.
(ii) The facility must establish written
procedures for initiation of restraint or seclusion in the absence of a
physician, which must be in conformance with applicable Federal regulations and
Mental Hygiene Law section 33.04.
(7) Assessment and monitoring. The condition
of the patient who is in a restraint or in seclusion must continuously be
assessed and monitored by trained and competent staff to ensure his or her
physical safety and condition.
(i) An
assessment of the patient's condition shall be made at least once every 30
minutes (or at more frequent intervals if directed by the physician), by a
registered professional nurse, nurse practitioner, or physician assistant
responsible for the care of the patient.
(ii) Restraint or seclusion must be
reevaluated and ended at the earliest possible time, based on the assessment
and reevaluation of the patient's condition by trained and competent staff.
Assessment and monitoring activities shall be detailed in facility policies and
procedures.
(8) Release.
A patient shall be released from restraint or seclusion as soon as such
restraint or seclusion is no longer needed to prevent the continuation or
renewal of an emergency and, in no event, later than the achievement of the
early release criteria or the expiration of an original order for such
restraint or seclusion, unless such order is renewed with a new order. Upon
release from restraint or seclusion, a registered nurse shall observe,
evaluate, and document the patient's physical and psychological condition. At
no time shall the patient be kept in restraint or seclusion without a written
order by a physician for a period exceeding one hour.
(9) Documentation. Documentation of episodes
of restraint and/or seclusion shall include:
(i) a description of the patient's behavior
and the intervention used;
(ii) the
rationale for the use of restraint and/or seclusion;
(iii) the failure of less restrictive
interventions, including those outlined in the patient's behavior management
plan; and
(iv) the patient's
response to the use of restraint and/or seclusion.
(10) Post event analysis and debriefing
activities. A facility shall ensure that post event analysis and debriefing
activities, occur after each episode of restraint or seclusion in order to
determine what led to the incident, what might have been prevented or curtailed
it, and how to prevent future episodes.
(i)
Post event analysis and debriefing procedures must be identified in facility
policies developed in accordance with paragraph (12) of this
subdivision.
(ii) Facilities must
ensure that all post event analyses and debriefings occur consistent with
applicable regulations of the Center for Medicare and Medicaid Services and
accrediting body standards.
(11) Education and training. Education and
training.
(i) All staff who have direct
patient contact must have ongoing education and training, and must demonstrate
competence in the techniques and alternative methods for handling behavior,
symptoms, and situations that traditionally have been treated through the use
of restraints or seclusion, and in the proper and safe use of seclusion and
restraint application.
(ii)
Providers subject to this section must utilize training and education programs
that have been approved by the office for this purpose. The office shall ensure
that current information identifying approved training and education is readily
available to providers who must comply with this section.
(12) Policies and procedures. Facilities
operated or licensed by the office which are authorized to utilize restraint or
seclusion to manage violent or self-destructive behavior shall have policies
which clearly articulate restraint reduction as an organizational value, set
forth the organization's intent to advance positive behavior management and
restraint reduction efforts, and specify the conditions under which restraint
and seclusion shall be used, and the procedures for the initiation of such use
to manage violent behavior that places the patient or others in
danger.
(13) Reporting.
(i) The use of restraint and/or seclusion
shall be reported to the office as, and in a format, specified by the office,
including, but not limited to:
(a) rate of
restraint or seclusion use;
(b)
total hours of restraint and seclusion use as a proportion of total inpatient
hours; and
(c) client and staff
injury rates related to restraint or seclusion; and
(ii) In addition to any other applicable
reporting requirements set forth in Federal or State law, any death that occurs
while a patient is restrained or in seclusion for behavioral management
purposes, or where it is reasonable to assume that a patient's death is a
result of such restraint or seclusion, or as otherwise set forth in applicable
Federal regulations, shall be reported to the Federal Centers for Medicare and
Medicaid Services.
(14)
Special program requirements. Consistent with the definitions established in
subdivision (a) of this section, and subject to more stringent Federal
regulations of the Centers for Medicare and Medicaid Services:
(i) State operated psychiatric centers.
Restraint or seclusion in State operated psychiatric centers shall be utilized
in accordance with Mental Hygiene Law section 33.04 and official policies of
the office. Nothing in this section shall preclude the application of security
measures during transportation of patients who are committed to a facility
pursuant to an order of a criminal court or who have been admitted to a
facility in accordance with article 10 of the Mental Hygiene Law.
(ii) Hospitals and inpatient facilities.
Restraint or seclusion in hospitals governed by Part 582 of this Title, and
psychiatric inpatient units of general hospitals governed by Part 580 of this
Title, shall be utilized in accordance with Mental Hygiene Law section 33.04
and the provisions of this section, and
42 CFR section
482.13.
(iii) Residential treatment programs for
children and youth. Restraint in inpatient psychiatric facilities governed by
Part 584 of this Title shall be utilized in accordance with Mental Hygiene Law
section 33.04 and the provisions of this section,
42 CFR sections
483.356,
483.358,
483.360,
483.362,
483.364,
483.366,
483.368,
483.370,
483.372,
483.374, and
483.376,
and provided further:
(a) Seclusion in such
facilities shall not be utilized unless pursuant to a written plan previously
approved by the office.
(b) Upon
admission, the facility must notify and supply a copy of the facility's
restraint and seclusion policy to all patients or, if the patient is a minor,
to the patient's parent or legal guardian. The policy must be communicated in
an accessible format, must include contact information for the Justice Center
for the Protection of People with Special Needs and receipt by the patient,
parent, or legal guardian must be acknowledged in writing and filed in the
patient's record.
(c) After
initiation of restraint or seclusion as an emergency safety intervention for a
minor patient, the facility must notify the parent(s) or legal guardian(s) as
soon as possible. A record of the facility's contact with such person must be
documented in the patient's record, including the date and time of notification
and the name of the staff member who provided the notification.
(iv) Comprehensive psychiatric
emergency programs. Restraint or seclusion in comprehensive psychiatric
emergency programs governed by Part 590 of this Title shall be utilized in
accordance with Mental Hygiene Law section 33.04, Part 590 of this Title, and
applicable Federal regulations.
(v)
Outpatient treatment for adults or children. Restraint or seclusion shall not
be utilized in outpatient treatment programs for adults or children governed by
Part 599 or 587 of this Title, including: clinic treatment programs for adults;
clinic treatment programs serving children; continuing day treatment programs;
day treatment programs serving children; partial hospitalization programs;
intensive psychiatric rehabilitation treatment programs; and any other programs
governed by such Part. Staff of such programs must have ongoing education and
training, and must demonstrate competence, in techniques and alternative
methods for safely handling escalating or aggressive behavior.
(vi) Residential programs for adults.
Restraint or seclusion shall not be utilized in residential programs for adults
governed by Part 595 of this Title. Each residential program must include in
its functional program, developed in accordance with section
595.7 of Part
595 of this Title, emergency procedures that will be followed to manage
violent, aggressive behavior that places the resident or others in danger.
Staff of residential programs for adults must have ongoing education and
training, and must demonstrate competence, in techniques and alternative
methods for safely handling crisis situations.
(vii) Licensed housing programs for children.
Restraint and seclusion shall not be utilized in licensed housing programs for
children governed by Part 594 of this Title. Each licensed housing program for
children must have ongoing education and training, and must demonstrate
competence, in techniques and alternative methods of safely handling crisis
situations.
(viii) Personalized
recovery oriented services. Restraint and seclusion shall not be utilized in
personalized recovery oriented services programs governed by Part 512 of this
Title. Each personalized recovery oriented services program must have ongoing
education and training, and must demonstrate competence, in techniques and
alternative methods of safely handling crisis situations.
(ix) Other programs licensed by the office.
Unless specifically authorized in regulations establishing any other program
category governed by the office, restraint or seclusion shall not be
utilized.
(x) In situations in
which alternative procedures and methods not involving the use of physical
force cannot reasonably be employed, nothing in this section shall be construed
to prohibit the use of reasonable physical force when necessary to protect the
life and limb of any person, for the purpose of restoring safety.
(d) Restraint for medical post-surgical procedures.
(1)
The use of restraints for medical-post surgical purposes in programs operated
or licensed by the office shall be in accordance with the same provisions
governing the use of restraints set forth by the Department of Health in 10
NYCRR section 405.7 or the Centers for Medicare and Medicaid Services,
whichever are stricter.
(2)
Hospitals, and other programs operated or licensed by the office which utilize
restraint for medical post-surgical purposes, shall have policies and
procedures for the initiation of restraint or seclusion for such use. Such
policies and procedures may be included with the policies and procedures for
the initiation of restraint or seclusion for behavioral management purposes, or
may be discrete.
(e) Guidelines of the office.
The office shall develop guidelines to assist providers in complying with the provisions of this section and in achieving restraint and seclusion reduction goals. The office shall post such guidelines on its public website.
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