Ariz. Admin. Code § R9-21-204 - Restraint and Seclusion

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.

Notes

Ariz. Admin. Code § R9-21-204

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, §61, effective September 30, 1993 (Supp. 93-3). Amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by final rulemaking at 22 A.A.R. 2019, effective 7/12/2016.