Utah Admin. Code R432-101-23 - Physical Restraints, Seclusion, and Behavior Management

(1) The licensee shall ensure physical restraints, including seclusion are only be used to protect the patient from injury to themself or to others or to assist patients to attain and maintain optimum levels of physical and emotional functioning.

(2) The licensee shall ensure restraints are not used for the convenience of staff, for punishment or discipline, or as substitutes for direct patient care, activities, or other services.

(3) Each hospital shall develop written policies and procedures that govern the use of physical restraints and seclusion and shall ensure the major focus of these policies is to provide patient safety and ensure civil and patient rights.

(4) The licensee shall ensure policies incorporate and address the following:

(a) examples of the types of restraints and safety devices that are acceptable for use and possible patient conditions dictating when the restraint may be used; and

(b) guidelines for periodic release and position change or exercise, with instructions for documentation of this action.

(5) The licensee may not use bed sheets or other linens as restraints.

(6) The licensee shall ensure restraints do not unduly hinder evacuation of the patient in the event of fire or other emergency.

(7)

(a) A member of the medical staff shall authorize restraints in writing every 24 hours.

(b) A licensee may not use PRN or as-needed orders for a restraint.

(c) If a physical restraint is used in behavior management, the licensee shall develop and follow an individualized behavior management program and an ongoing monitoring system to assure effectiveness of the treatment.

(d) The licensee shall ensure the use of restraints is reviewed routinely in the interdisciplinary team meeting, as the order is renewed by the member of the medical staff, and on a daily basis as care is delivered. This is an ongoing process that the licensee shall ensure is documented in the patient's record.

(e) The licensee may use physical restraints, including simple safety devices, only if a specific hazard or need for restraint is present.

(f) The physician order shall indicate the type of physical restraint or safety device that may be used and the length of time it may be used.

(g) The licensee shall develop and follow a restraint policy addressing Subsections R432-101-23(7)(a) through (f) and included in the patient care plan.

(8) The licensee shall ensure physical restraints are:

(a) applied by properly trained staff to ensure a minimum of discomfort, allowing sufficient body movement to ensure that circulation will not be impaired;

(b) not used or applied in a manner that causes injury or the potential for injury;

(c) are each monitored and assessed by staff: and

(d) are released or the patient's position changed at least every two hours, unless written justification is provided for why such restraint release is dangerous to the patient or others.

(9) Physical restraints may be used in an emergency, if there is an obvious threat to life or immediate safety, as follows:

(a) verbal orders may be given by the physician to a licensed nurse by telephone;

(b) a licensed health care professional, identified by policy, may initiate the use of a restraint, only if verbal or written approval from the physician is obtained within one hour;

(c) a physician shall sign any verbal order within 24 hours; and

(d) staff members document the circumstances necessitating emergency use of the restraint and the patient's response in the patient record.

(10) The licensee shall ensure seclusion is used in accordance with hospital policy and authorized by a member of the medical staff.

(11)

(a) If seclusion is used for behavior management, the licensee shall ensure there is an individualized behavior management program and an ongoing monitoring system to assure effectiveness of the treatment.

(b) The licensee shall ensure the use of seclusion is reviewed routinely in the interdisciplinary team meeting, as the order is renewed by the member of the medical staff, and on a daily basis as care is delivered. This is an ongoing process that the licensee shall ensure is documented in the patient's record.

(c) The licensee shall ensure staff monitors a patient in seclusion for adverse effects and documents the monitoring evaluations in the patient record.

(12) The licensee shall ensure time out is used in accordance with hospital policy and may be used without authorization by a member of the medical staff for each use.

(13) The licensee shall ensure the use of time out is included in the patient care plan and documented in the patient record.

(14) The licensee shall ensure behavior management policy:

(a) establishes criteria for admission and retention of patients who require behavior management programs;

(b) specifies the data required and the location of the data in the clinical record;

(c) is developed by the interdisciplinary team;

(d) provides an opportunity for involvement of the patient, next of kin or designated representative in the interdisciplinary team; and

(e) describes the team leader's approval process of a behavior management program for a patient.

(15) The licensee shall ensure the behavior management program:

(a) employs the least restrictive methods to produce the desired outcomes and incorporate a process to identify and reinforce desirable behavior;

(b) includes consent for use of any behavior management program that employs aversive stimuli from the patient, next of kin, or designated representative;

(c) is incorporated into the patient care plan; and

(d) is reviewed routinely by an interdisciplinary team, as the order is renewed by the member of the medical staff, and on a daily basis as care is delivered. This is an ongoing process that the licensee shall ensure is documented in the patient's record.

(16) The licensee shall ensure behavior management documentation in the patient's record includes:

(a) a behavior baseline profile, including a description of the undesirable behavior, as well as a statement whether there is a known history of previous undesirable behaviors and previous treatment;

(b) conditions when the behavior occurs;

(c) interventions used and their results;

(d) a behavior management program including specific measurable behavioral objectives, time frames, names, titles, and signature of the person responsible for conducting the program and monitoring and evaluation methods; and

(e) summaries and dates of the evaluations and reviews by the interdisciplinary team.

Notes

Utah Admin. Code R432-101-23

Amended by Utah State Bulletin Number 2023-22, effective 11/1/2023