10.1.
General. Patients have the right to freedom from seclusion or mechanical
restraints unless otherwise clinically indicated and consistent with the
applicable standard of care as provided herein. Seclusion and restraint shall
only be used when there is imminent danger that the patient will injure himself
or herself or others and when all other less restrictive measures have been
exhausted or no less restrictive measures are reasonably available. Seclusion
or mechanical restraints that are used solely as a means of coercion,
discipline, convenience, or retaliation are prohibited.
The use of restraint or seclusion shall only be administered
in accordance with the order of a physician or psychiatrist or, in their
absence, an advanced nurse practitioner or physician's assistant responsible
for the care of the patient. A registered nurse who is trained in crisis
intervention may initiate the emergency application of restraint or seclusion
prior to obtaining such an order: Provided, That the emergency
application of restraints or seclusion requires that the registered nurse
obtain an order forthwith after the restraint or seclusion has been applied.
Under no circumstance may orders for the use of restraint or seclusion ever be
written or provided as a standing order or on an as needed basis.
10.2. Seclusion and Restraint.
Seclusion of any patient or mechanical restraints for any patient, or both, may
be administered only as expressly permitted by
42 C.F.R. §
482.13(e). The use, time
period for use, and documentation of the use of seclusion or mechanical
restraints, or both, in the patient's medical record shall be done in
accordance with 42 C.F.R. § 482 and the State Operations Manual:
Provided, That seclusion or mechanical restraints for
developmentally disabled patients are prohibited and only the "time out"
procedure developed specifically for each such patient in his or treatment plan
and in accordance with applicable law may be used for a developmentally
disabled patient.
All personnel at a mental health facility who administer or
assists in the administration of seclusion or the use of mechanical restraints
shall undergo training as required by
42 C.F.R. §
482.13(f) and shall further
complete subsequent periodic training no less frequently than annually
regarding the use of seclusion and or mechanical restraints.
10.3. Time. The time spent in seclusion shall
be the shortest time required for the patient to regain his or her
self-control.
10.4. Seclusion
Inappropriate for Suicidal Patients. Seclusion shall not be used for a patient
who is actively suicidal or for a patient for whom constant observation has
been ordered. If the physician determines that seclusion is necessary, the need
for such seclusion shall be documented in the patient's medical record and
one-on-one observation of the patient shall be required.
10.5. Items Entitled During Seclusion. A
patient who is placed in seclusion is entitled to clothing, a bed, a mattress,
bedding, reading matter, stationery, and similar items. Only when it is
determined that a specific item may be harmful to the patient may the item be
withheld. The order for seclusion shall specify those items which are to be
removed and the reasons for their removal.
10.6. Supervision of Seclusion Room. Any room
used for seclusion shall be in an area that permits constant supervision by
staff.
10.7. Seclusion Room
Supervision. The registered nurse in charge of the unit or shift is responsible
for assuring that the following seclusion room checks, and procedures are
carried out:
10.7.1. Each patient in seclusion
shall be checked no less frequently than every five minutes and as required by
42 C.F.R. §
482.13. The seclusion room "check sheet"
shall be updated to assure the presence and safety of the patient in the
seclusion room;
10.7.2. The patient
shall have access to fluids and to the toilet hourly. Meals shall be delivered
at regular meal times. Compliance with these requirements shall be documented
on the check sheet; and
10.7.3. The
case manager, when available, or the registered nurse in charge of the unit or
shift shall talk directly with the secluded patient and assess the need for
continued seclusion at least once every hour.
10.8. Supervision of Mechanical Restraints.
Supervision of patients in mechanical restraints shall be on a one-to-one basis
for the duration of the time the restraints are in place. The procedure for the
application of mechanical restraints shall be followed to assure that no
restraint is applied in a manner as to produce physical pain or damage to the
patient. Opportunity for motion and exercise shall be provided for a period of
not less than 10 minutes during each two hours in which restraint is
employed.
10.9. Handcuffs
Unacceptable. Handcuffs are not considered an acceptable form of restraint for
patients and shall not be used for that purpose.
10.10. Continued Hourly Assessment. The case
manager, when available, or the registered nurse in charge of the unit or shift
shall talk directly with the restrained patient and assess the need for
continued restraint at least once every hour.
10.11. Punishment or Convenience. Mechanical
Restraints shall not be used as punishment or for the convenience of
staff.
10.12. Limitation on Use of
Chemical Restraint. Drugs or medications shall not be used as punishment, for
the convenience of staff, as a substitute for adequate staffing, or as a
substitute for a treatment plan. Drugs and medication may only be administered
pursuant to informed consent in the absence of a psychiatric
emergency.
10.13. Copies. All
documentation related to the seclusion or restraint of a patient shall be done
in accordance with the applicable standard of care,
42 C.F.R. §
482.13, and the State Operations
Manual.
10.14. Trial Release
Procedure for Seclusion and Restraint. Seclusion and restraint are intended to
provide external controls for the protection of the patient or to prevent the
patient from injuring others. Continued use of the controls beyond the time
when they are clinically indicated is inappropriate. It is the responsibility
of the nurse on duty to assure that the seclusion or restraint measures are
stopped when the behavior of the patient makes their continued use unnecessary
and to further inform the ordering physician promptly of events that support
the cessation of seclusion or restraints.
