Ohio Admin. Code 5122-26-16.1 - Restraint and seclusion
(A)
The purpose of
this rule is to state the specific requirements applicable to restraint and
seclusion.
(B)
The requirements for the use of mechanical restraint or
seclusion do not apply:
(1)
To mechanical restraint use that is only associated
with medical, dental, diagnostic, or surgical procedures and is based on
standard practice for the procedure. Such standard practice may or may not be
described in procedure or practice descriptions (e.g., the requirements do not
apply to medical immobilization in the form of surgical positioning, iv arm
boards, radiotherapy procedures, electroconvulsive therapy,
etc.);
(2)
When a device is used to meet the assessed needs of an
individual who requires adaptive support (e.g., postural support, orthopedic
appliances) or protective devices (e.g., helmets, tabletop chairs, bed rails,
car seats). Such use is always based on the assessed needs of the individual.
Periodic reassessment should assure that the restraint continues to meet an
identified individual need;
(3)
To forensic and
corrections restrictions used for security purposes, i.e., for custody,
detention, and public safety reasons, and when not involved in the provision of
health care.
(C)
In addition to the definitions in rule
5122-24-01 of the Administrative
Code, the following definitions apply to this rule:
(1)
"Licensed
independent practitioner" means an individual who is authorized by the provider
to order seclusion and restraint. A licensed independent practitioner includes
a "medical practitioner authorized to order seclusion and restraint" as defined
in this paragraph, as well as any other practitioner that has ordering
seclusion and restraint in their scope of practice.
(2)
"Medical
practitioner authorized to order seclusion and restraint" means an individual
who is authorized by the provider to order seclusion and restraint and who is a
psychiatrist or other physician, or a physician's assistant, certified nurse
practitioner or clinical nurse specialist authorized to order restraint or
seclusion in accordance with their scope of practice and as permitted by
applicable law or regulation.
(3)
"Order" means
written or verbal authorization to implement seclusion or
restraint.
(D)
Restraint or seclusion will not be used unless it is in
response to a crisis situation, i.e., where there exists an imminent risk of
physical harm to the individual or others, and no other safe and effective
intervention is possible. It will be employed for the least amount of time
necessary in order that the individual may resume his/her treatment as quickly
as possible.
(E)
The following are disallowed:
(1)
PRN and standing
orders for seclusion or restraint.
(2)
Restraint and
seclusion may not be used simultaneously.
(3)
Mechanical
restraint may not be used on an individual under age eighteen.
(F)
Ordering restraint or seclusion.
(1)
For all settings
other than a psychiatric residential treatment facility (PRTF), a physical
restraint must be authorized by a trained, qualified staff member in accordance
with the requirements of the providers' behavioral health national accrediting
body or if the organization does not have national accreditation, as identified
and approved by the provider's policy. A licensed independent practitioner or
practitioner with dependent licensure under supervision will review each
incident of physical restrain as soon as possible but not later than
seventy-two hours, and if required by national accreditation body, provide an
order for the physical restraint in the client records.
(2)
For all settings
other than a PRTF, seclusion or mechanical restraint orders will be in writing
and issued by a licensed independent practitioner or a practitioner with
dependent licensure under supervision and include the date and time the order
was written or obtained.
(3)
In a PRTF, the order for physical restraint, mechanical
restraint, or seclusion, will be in writing and issued by a licensed
independent practitioner or a practitioner with dependent licensure under
supervision and include the date and time the order was written or
obtained.
(4)
In all circumstances, the order for restraint or
seclusion will be the least restrictive intervention that is most likely to be
effective in resolving the emergency safety situation based on consultation
with staff and specify the type of intervention and the maximum length of time.
The order will also note the order is limited to the duration of the emergency
safety situation.
(5)
Verbal orders.
(a)
When an
individual authorized to order seclusion and restraint in paragraph (F)(2) or
(F)(3) of this rule is not available in person to order restraint or seclusion
or immediate intervention is required, agency policy may permit staff to obtain
a verbal order from a licensed independent practitioner or a practitioner with
dependent licensure under supervision while the restraint or seclusion is being
initiated by staff or immediately after the intervention ends.
(b)
The verbal order
will be signed by a licensed independent practitioner or a practitioner with
dependent licensure under supervision or independent licensure, at least either
by the end of the work day or in a residential setting during the next
scheduled shift.
(6)
Written and
verbal orders may be written for a maximum of:
(a)
Two hours for
restraint or seclusion of adults eighteen years of age or
older;
(b)
One hour for restraint or seclusion of children and
adolescents age nine through seventeen; or
(c)
Thirty minutes
for restraint or seclusion of children under age nine.
(7)
If
restraint is necessary as a means of safely transporting an individual to
seclusion, a separate order is not needed. However, the initial order for the
seclusion will include the physical transport restraint and be consistent with
the standards for restraint/seclusion orders.
(8)
If the restraint
or seclusion continues past the original time in the order, staff will contact
the individual who issued the original order who will issue a new written or
verbal order if seclusion or restraint is to be continued. In a PRTF, a
licensed practical nurse or registered nurse will be the person who contacts
the medical practitioner, and a restraint or seclusion may not be continued
past the time limits in paragraph (F)(6) of this rule.
(9)
If the restraint
or seclusion episode is concluded, and the client's behavior necessitates
initiating another restraint or seclusion, then a new order will be obtained,
even if the ending time of the original order has not passed.
(G)
Implementation of restraint or seclusion.
(1)
Restraint or
seclusion will be discontinued at the earliest possible time, regardless of the
length of time identified in the order.
(2)
A trained and
qualified practitioner with appropriate training in seclusion and restraint and
in accordance with their scope of practice will conduct assessment of the
physical and psychological well-being of the individual in accordance with the
provider's national accrediting body. If not nationally accredited, a licensed
practitioner will conduct the assessment within two hours of the initiation of
the seclusion or restraint intervention. The assessment will either be
conducted in person, face-to-face, or via interactive videoconferencing based
on the individual's clinical and medical needs. Interactive videoconferencing
will only be used if appropriate for the individual. In a PRTF, this assessment
will be in person, face-to-face, within one hour of the initiation of the
seclusion or restraint intervention and conducted by a medical practitioner
authorized to order seclusion and restraint or a registered nurse. The
assessment is to be conducted even if the seclusion or restraint intervention
is ended before one hour. The assessment is to include, but is not limited
to:
(a)
The
individual 's physical and psychological status;
(b)
The individual 's
behavior;
(c)
The appropriateness of the intervention measures;
and
(d)
Any complications resulting from the
intervention.
(3)
Monitoring while in and immediately after seclusion or
restraint.
(a)
Restraint.
(i)
A staff trained in the use of restraint will be
physically present, continually assessing and monitoring the physical and
psychological well-being of the individual and the safe use throughout the
duration of the intervention.
(ii)
Documentation of
the condition of the person will be made in the clinical record at routine
intervals not to exceed fifteen minutes or more often if the person's condition
so warrants. Such documentation will address at a minimum, attention to
respiration, the individual's physical status and behavior, the need for
continued restraint, and other needs as necessary, and the appropriate actions
taken.
(b)
Seclusion.
(i)
A staff trained in the use of seclusion will be
physically present either in or immediately outside the seclusion room,
continually assessing and monitoring the physical and psychological wellbeing
of the individual and the safe use throughout the duration of the
intervention.
(ii)
Documentation of the condition of the person will be
made in the clinical record at routine intervals not to exceed fifteen minutes
or more often if the person's condition so warrants. Such documentation will
address at a minimum, attention to respiration, the individual's physical
status and behavior, the need for continued seclusion, and other needs as
necessary, and the appropriate actions taken.
(iii)
If seclusion
lasts longer than ten minutes, the person will be given adequate access to the
restroom and water at least every thirty minutes.
(c)
At the conclusion
of the restraint or seclusion, a licensed medical staff will immediately check
the resident for any injuries, evaluate the individual's psychological
well-being and document the results.
(4)
Staff will assure
that a client injured during a restraint or seclusion intervention receives
immediate medical treatment that is appropriate for the specific injury,
including transfer to a hospital for evaluation and treatment if
needed.
(5)
Transitional holds are not seclusion or restraint, and
are not subject to this rule.
(H)
Notification of
the use of seclusion or restraint.
(1)
If the client is a minor, the provider will notify the
parent(s), custodian(s) or legal guardian(s) of the individual who has been
restrained or placed in seclusion as soon as possible after the initiation of
each episode; and in a PRTF the notification will occur within twenty-four
hours of the intervention..
(2)
If the client is
an adult, the provider will notify the client's guardian, when applicable, or
family or significant other when the client has given their consent for such
notification, within twenty-four hours of initiation of each
episode.
(3)
The provider will document in the client's record that
the notification was made, including the date and time of notification, the
name of the person(s) notified and the name of the staff person providing the
notification.
(I)
Debriefing.
(1)
Within twenty-four hours after the use of restraint or
seclusion, all staff directly involved in a seclusion or restraint intervention
and the client will have a face-to-face discussion. This discussion will
include all staff involved in the intervention except when the presence of a
particular staff person may jeopardize the well-being of the client. Other
staff and the client parents, custodian or guardian may participate in the
discussion when it is deemed appropriate by the provider.
(a)
The discussion
will include the circumstances resulting in the use of seclusion or
restraint.
(b)
The discussion will include identifying techniques and
tools that might help the individual regulate their own behavior in the future
and modifications to the individual's crisis plan.
(c)
The outcome and
any injuries that may have resulted from the use of seclusion or
restraint.
(d)
The discussion will include any other element as
required by the provider's national accrediting body as part of a debriefing
process. This may include a separate staff debriefing.
(e)
The debriefing
will be conducted in a language understood by the client, and their parent,
custodian, or guardian.
(f)
In non-PRTF settings the client debriefing may be
delayed if the client refuses, is not available, or the debriefing is
clinically not appropriate at that time. The debriefing will be conducted as
soon as practical and prudent.
(2)
A PRTF, in
addition to the briefing set forth in paragraph (I)(1) of this rule, will
conduct a staff only debriefing session within twenty-four hours after the use
of restraint or seclusion. The debriefing will include all staff involved in
the intervention and appropriate supervisory and administrative staff. The
debriefing session will include at a minimum a review and discussion of:
(a)
The situation
that necessitated the intervention, including a discussion of the precipitating
factors that led up to the intervention;
(b)
Alternative
techniques that might have prevented the use of the restraint or
seclusion;
(c)
The procedures, if any, that staff are to implement to
prevent any recurrence of the use of restraint or seclusion;
and
(d)
The outcome and any injuries that may have resulted
from the use of restraint or seclusion.
(3)
Staff will
document in the record for each client who is debriefed the number of
debriefing sessions that took place, the names of staff who were present for
the debriefing, names of staff that were excused from the debriefing, and any
changes to the individual's treatment plan that result from the
debriefings.
(4)
Debriefings may be conducted via virtual
means.
(J)
Staff involved in a restraint or seclusion intervention
that results in an injury to a client or staff will meet with supervisory staff
and evaluate the circumstances that caused the injury and develop a plan to
prevent future injuries. This documentation may be included with the client's
debriefing or contained elsewhere. The plan to prevent future injuries is to
include at a minimum attention to revised procedures, and new or additional
staff training.
(K)
Documentation.
(1)
Each order for
restraint or seclusion as set forth in paragraph (F) of this
rule.
(2)
The date, day of week, time and shift the restraint or
seclusion began and the duration.
(3)
The type of
method, including type of physical hold or mechanical restraint
utilized.
(4)
The client's behavior that resulted in the client being
restrained or put in seclusion.
(5)
Attempts to offer
alternatives to the client based upon their crisis plan or deescalation
techniques, as applicable
(6)
Each attempt to use less restrictive interventions, and
the results.
(7)
The time and results of the assessment in paragraph
(G)(2) of this rule.
(8)
The time and results of the on-going monitoring in
paragraph (G)(3) of this rule.
(9)
The name of all
staff involved in the restraint or seclusion, including the staff that conducts
the assessment and the staff who ordered the restraint or
seclusion.
(10)
Any psychotropic medications utilized during the
restraint or seclusion.
(11)
All injuries that occur as a result of the restraint or
seclusion, including injuries to staff resulting from the intervention.
Detailed information about any staff injury may be maintained outside the
client's ICR. The appropriate actions taken for any injuries noted will also be
documented.
(L)
Seclusion room requirements.
(1)
Appropriate temperature control, ventilation and
lighting;
(2)
Safe wall and ceiling fixtures, with no sharp
edges;
(3)
The presence of an observation window and, if
necessary, wall mirror(s) so that all areas of the room are observable by staff
from outside of the room; and
(4)
That any
furniture present is removable or is securely fixed for safety
reasons.
(M)
Clinically appropriate reason for the inability to
implement any portion of this rule will be documented in the clinical record,
and will be addressed in any staff de-briefing of the episode and in the
provider's performance improvement process.
Replaces: 5122-26-16.1
Notes
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 01/01/1991, 04/16/2001, 01/01/2012, 04/01/2016
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