Utah Admin. Code R432-150-13 - Restraint Policy

(1) Each resident has the right to be free from physical and chemical restraints imposed for purposes of discipline or convenience, or not required to treat the resident's medical symptoms.
(2)
(a) The licensee shall have written policies and procedures regarding the proper use of restraints.
(b) The licensee shall ensure physical and chemical restraints are only used to assist a resident to attain and maintain optimum levels of physical and emotional functioning.
(c) The licensee shall ensure physical and chemical restraints are not used as substitutes for direct resident care, activities, or other services.
(d) The licensee shall ensure restraints do not hinder evacuation of the resident in the event of fire or other emergency.
(e) If use of a physical or a chemical restraint is implemented, the licensee shall ensure the resident and responsible person are informed of the reasons for the restraint, the circumstances that allow the restraint to be discontinued, and the hazards of the restraint, including potential physical side effects.
(3) The licensee shall develop and implement policies and procedures that govern the use of physical and chemical restraints, promote optimal resident function, minimize adverse consequences of restraint use and incorporate and address:
(a) examples of the types of restraints and safety devices that are acceptable for the specified use and possible resident conditions when the restraint may be used;
(b) govern the use of physical and chemical restraints;
(c) incorporate and address:
(i) resident assessment criteria that includes:
(A) appropriateness of use;
(B) behavior management and modification protocols including possible alterations to the physical environment;
(C) less restrictive alternatives before the use of more restrictive measures;
(D) procedures for use; and
(E) purpose and nature of the restraint;
(d) minimize adverse consequences of restraint use;
(e) physical restraint guidelines for periodic release and position change or exercise, with instructions for documentation of this action; and
(f) safely and therapeutically promote optimal resident function.
(4) The licensee shall ensure emergency use of physical and chemical restraints comply with:
(a) a physician, a licensed health practitioner, the director of nursing, or the health services supervisor authorizes the emergency use of restraints;
(b) the attending physician is notified as soon as possible, but at least within 24 hours of the application of the restraints;
(c) the circumstances necessitating emergency use of the restraint and the client's response is documented in the resident's record; and
(d) the director of nursing or health services supervisor is notified no later than the beginning of the next day shift of the application of the restraints.
(5) The licensee shall ensure:
(a) any medication given to a resident is administered according to the requirements of professional and ethical practice and according to the policies and procedures of the facility;
(b) chemical restraints are authorized in writing by a licensed practitioner and incorporated in the resident's care plan in conjunction with an individualized behavior management program;
(c) each resident receiving chemical restraints is monitored for adverse effects that significantly hinder verbal, emotional, or physical abilities;
(d) leather restraints, straight jackets, or locked restraints are prohibited;
(e) physical restraints are authorized in writing by a licensed practitioner and incorporated in the resident's care plan;
(f) staff application of physical restraints do not cause injury or allow a potential for injury;
(g) staff application of physical restraints ensures minimal discomfort to the resident and allow sufficient body movement for proper circulation;
(h) the resident care conference team reviews and documents the use of chemical restraints during each resident care conference and upon receipt of renewal orders from the licensed practitioner;
(i) the resident care conference team reviews and documents the use of physical restraints, including simple safety devices, during each resident care conference, and upon receipt of renewal orders from the licensed practitioner; and
(j) the resident's care plan includes:
(i) the frequency of release;
(ii) the length of time to be used;
(iii) the type of exercise or ambulation provided; and
(iv) the type of physical restraint or safety device.
(6) The licensee shall initiate gradual drug dosage reductions as outlined in Subsection R432-150-15(13)(c).
(7) The licensee shall include criteria for admission and retention of a resident who requires behavior management program in the facility policy.

Notes

Utah Admin. Code R432-150-13
Amended by Utah State Bulletin Number 2024-01, effective 12/12/2023 Amended by Utah State Bulletin Number 2025-05, effective 2/18/2025

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