National Standards & Definitions for Restraint & Seclusion

Standard or Definition

CMS Psychiatric Residential Treatment Facilities

CMS Hospital

CWLA Best Practice Guidelines

COA 7th Edition

JCAHO Behavioral Health

Restraint Definition

Physical Restraint "any personal restraint, mechanical restraint or drug used as a restraint as defined in section CFR 483.352 (3).

Mechanical Restraint Ė any device attached or adjacent to the patientís body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body.

 

Physical Restraint is any manual method or physical or mechanical device, material or equipment, attached or adjacent to the patientís body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body.

Physical Restraint - The application of physical force by one or more individuals that reduces or restricts the ability of an individual to move his arms, legs or head freely.

Mechanical Restraint - The use of any mechanical device to limit movement and prevent harm to self or others,

Restraint, Manual - "The practice of holding a person's arms, legs or head to prevent harm to self or others."

Restraint, Mechanical - The practice of using physical devices to limit movement of a person's arms, legs or head to prevent harm to self or others. Examples of mechanical restraints include but are not limited to: belts with cuffs and straightjackets."

Restraint is the direct application of physical force to an individual served with or without his or her permission to restrict his or her freedom of movement. The physical force may be human, Mechanical devices, or a combination thereof.

Restraint Exclusions

Personal restraint does not include briefly holding without undue force a resident in order to calm or comfort him or her, or holding a residentís hand to safely escort him or her from one area to another.

Excludes uses of restraint for acute medical and surgical procedures. Excludes the use of restrictive devices applied and monitored by law enforcement. Excludes a voluntary mechanical support used to achieve proper body alignment, Excludes a positioning or securing device used during medical procedures.

Physical restraint does not include the temporary physical holding of an individual to assist him/her to participate in activities of daily living. y

Mechanical restraint does not include devices such as orthopedically prescribed devices, surgical dressings, protective helmets, or any methods of holding for the purpose of conducting physical examination or tests, or to protect the individual from falling out of bed, or to permit the individual to participate in activities of daily living without risk of harm to the individual.

None specified

Exclusions for use with surgical procedures, when a staff member holds or redirects a child, without the childís permission, for 30 minutes or less, and to use of restraint with individuals who receive treatment through formal behavioral management programs Öand have exhibited intractable behavior that is injurious to self or others

Chemical Restraint Definition

A drug used as a restraint means any drug that is administered to manage a residentís behavior in a way that reduces the safety risk to the resident or others; has a temporary effect of restricting the residents freedom of movement; and is not a standard treatment for the patientís medical or psychiatric condition.

A drug used as a restraint is a medication used to control behavior or to restrict the patientís freedom of movement and is not a standard treatment for the patientís medical or psychiatric condition

The use of any psychoactive medication as a restraint to control behavior or restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychiatric condition.

Use of chemical restraint is prohibited by COA standards.

Definition Is not clear but seems consistent with CMS Ė key elements, medications that restrict movement, are prescribed at dosages outside of common practice, and are not standard treatment for the condition. Chemical restraints are prohibited by JCAHO.

Seclusion Definitions

The involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving

"The involuntary confinement of a patient alone in a room or an area where the person is physically prevented from leaving."

The placement of an individual against his will in any room where the door is unable to be opened voluntarily by the individual

Seclusion - "The practice of placing a person in a locked room to prevent harm to self or others."

Isolation - "The practice of separating a person from others in a monitored non-locked or quiet room in order to calm the person removed."

Not explicitly defined.

Seclusion Exclusions

Time-out is excluded if a resident in time-out is never physically prevented from leaving the time-out area, (time out can take place in their room alone or with other residents and staff must monitor the resident while he or she is in time out.

Seclusion does not include confinement on a locked ward or unit where the patient is with others. Seclusion is not just confining an individual to an area but involuntarily confining him or her alone in a room or area where he/she is physically prevented from leaving."

Time out is excluded. (A child may not be placed in time out behind a closed door unless a caregiver is present.)

Time out is excluded.

Excludes time-out in an unlocked room for less than 30 minutes. Excludes instances in which an individual is restricted to an unlocked room or area, consistent with a unitís rules or regulations and an organizations policies and procedures.

Criteria for Restraint and Seclusion

483.358 Ė C) The physician must order the least restrictive emergency intervention that is most likely to be effective in resolving the emergency safety situation.

Emergency Safety situation means Ė unanticipated resident behavior that places the resident or others at serious threat of violence or injury if no intervention occurs and that calls for an emergency safety intervention.

An emergency safety intervention must be performed in a manner that is safe, proportionate, and appropriate to the severity of the behavior, and the residentís chronological, and developmental age, size, gender, physical, medical, and psychiatric condition; and personal history."

"A restraint must only be used in emergency situations if needed to ensure the patientís physical safety and less restrictive interventions have been determined to be ineffective." The patient has the right to be free from restraints of any form that are not medically necessary, or are used as a means of coercion, discipline, convenience, or retaliation by staff. Use only when other less restrictive measures have been found to be ineffective.

Never written as a standing order

Implemented in the least restrictive manner possible.

In accordance with safe and appropriate techniques.

Ended at the earliest possible time.

Physical interventions should used only in emergency circumstances and only to ensure the immediate safety of the individual or others when no less restrictive intervention has been, or is likely to be, effective in averting the danger.

Restraint and seclusion should never be used as a threat of punishment or form of discipline, in lieu of adequate staffing, as a replacement for active treatment, or for caregiver convenience.

Manual restraint and seclusion may be used "only in emergency or crisis situations to protect individuals from harming themselves or others, and only when "less restrictive measures have proven to be ineffective."

"The organization prohibits seclusion or restraint in non-crisis or emergency situations, as a form of discipline, or for convenience of staff."

Duration of isolation, seclusion and manual/mechanical restraint is limited to 15 minutes maximum time per episode for children aged nine and younger. Manual/mechanical restraint is limited to 30 minutes per episode for persons age ten and older. Isolation and seclusion are limited to one hour per episode for persons age ten and older.

 

Restraint and seclusion are used only in an emergency when there is an imminent risk of and individual physically harming himself or herself or others, including staff. Non-physical interventions are the first choice as an intervention, unless safety issues demand an immediate physical response.

Monitoring Requirements

"Clinical staff, trained in the use of emergency safety interventions, must be physically present, continually assessing and monitoring the psychological and physical well being of the resident and the safe use of restraint throughout the duration of the emergency safety situation. If the emergency safety situation continues beyond the time-limit of the order for the use of restraint, a registered nurse or other licensed staff must immediately contact the ordering physician, or other licensed practitioner permitted by the state and the facility to evaluate the residentís well-being to order restraint or seclusion to receive further instructions. Clinical staff trained in the use of emergency safety interventions, must be physically present in or immediately outside the seclusion room, continually assessing, monitoring, and evaluating the physical and psychological well-being of the patient in seclusion. Video monitoring does not meet this requirement."

"The condition of the restrained patient must be continually assessed, monitored, and reevaluated." The nature of what is assessed, monitored and evaluated is not specified but interpretive guidelines suggest that basic nursing standards regarding, respiration, circulation, range of motion, heart rate, etc. should be explicated and documented.

A trained observer should be present whenever possible; staff trained in the use of emergency interventions must be present. Consciousness, respiration, agitation, mental status, skin color, and skin integrity should be monitored continuously. Guidelines present a table for additional monitoring by intervention type.

Persons placed in isolation, mechanical restraint or manual restraint are "continuously monitored and assessed at least every 15 minutes for harmful health or psychological reactions."

Persons in seclusion must be monitored "face-to-face"

 

Individuals in restraint or seclusion are monitored. Monitoring is accomplished through continuous in-person observation by an assigned staff personÖ..After the first hour, a person in seclusion only, may be continuously monitored using simultaneous video and audio equipment, if this is consistent with the individualís condition or wishes.

Ordering and Initiation

Orders for restraint or seclusion must be by a physician, or other licensed practitioner permitted by the state and the facility to order restraint and seclusion and trained in the use of emergency safety interventions. If the residentís treatment team physician is available, only he or she can order restraint or seclusion. If the order is verbal, a licensed professional (nurse or LPN) must receive the order and it must be co-signed by the physician making the order. Orders must be limited to no longer than the duration of the emergency safety situation and under no circumstances exceed 4 hours for residents ages 18 to 21; 2 hours for residents ages 9 to 17; or 1 hour for residents under age 9. Each order must contain the date and time the order was obtained, the name of the licensed physician.

Restraint and seclusion must be used in accordance with the order of a physician or other LIP, Orders for R&S must never be written as PRN. The treating physician must be consulted as soon as possible, if the R or S is not ordered by the patientís treating physician.

Each written order for seclusion or restraint is limited to 4 hours for adults, 2 hours for children and adolescents 9 to 17, and 1 hour for patients under 9.

The original order may only be renewed in accordance with these rules for up to 24 hours.

Not specified.

Provider policies should address circumstances under which restrictive interventions may be utilized by caregivers.

 

"Authorization for use is provided by qualified personnel with appropriate credentials, skills, knowledge and expertise and in accord with federal, state or provincial requirements"

A board-certified physician's approval is required for any period of locked seclusion or mechanical restraint longer than 30 minutes.

An LIP (MD, PA, or APRN) orders the use of restraint or seclusion. The organization may authorize qualified RNís or other qualified trained staff members to initiate a restraint or seclusion before and order is obtained.

Written or verbal orders for initial and continuing use of restraint and seclusion are time-limited.

Verbal and written orders for restraint and seclusion are limited to: 4 hours for 18 and older; 2 hours for children and adolescents 9 to 17; and 1 hour for children under 9. If restraint or seclusion needs to continue beyond the expiration of the time-limited order, a new order for restraint or seclusion is obtained from and LIP primarily responsible for the individualís ongoing care, or his or her LIP designee.

Orders for the use of restraint and seclusion are not written as a standing order or PRN.

In-person Assessment

Within 1 hour of the initiation of the emergency safety intervention a physician or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological well being of the resident must conduct a face-to-face assessment of the physical and psychological well-being of the resident, including but not limited to; physical and psychological status, the residents behavior, the appropriateness of the intervention.

A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention.

Available internal medical personnel should monitor incidents in which physically restrictive interventions are employed.

Staff members identified as medical resources should have the authority to continue or stop a specific intervention based on health issues.

 

The LIP who is primarily responsible for the individualís ongoing care, or his or her LIP designee conducts an in-person evaluation within 4 hours of the initiation of restraint or seclusion for individuals 18 or older or within 2 hours for those under 18. If the individual is no longer in restraint or seclusion when an original verbal order expires, the LIP conducts an in-person assessment of the individual within 24 hours of the initiation of the restraint or seclusion.

Debriefing

"Within 24 hours after the use of restraint or seclusion, staff involved in an emergency safety intervention and the patient must have a face-to-face discussion."

"within 24 hours after the use of restraint or seclusion, all staff involved in the emergency safety intervention and an appropriate supervisory and Administrative staff must conduct a debriefing session that includes at a minimum, a review and discussion (cfr 483.370 (1-4c)"

No Standard or Requirement.

Within 24 hours after restraint or seclusion the caregivers involved and the child or youth should participate in a face-to-face discussion. Discussion can also include other staff and parents/guardian when appropriate. Include in the debriefing only those persons whose presence will not jeopardize the well-being of the child/youth.

Debriefing is conducted within 24 hours of each manual/mechanical restraint/ locked seclusion that includes appropriate personnel, the person served and his/her parent/legal guardian. Debriefing "evaluates the well-being of the person served; identifies the need for counseling or other services related to the incident; identifies antecedent behaviors and modifies the service plan as appropriate; and analyzes how the incident was handled and identifies needed changes to procedures and/or staff training."

The individual and staff participate in a de-briefing about the restraint or seclusion episode. The individual, and, if appropriate, the individualís family, participate with staff who were involved with the incident, and who are available, in a debriefing about each episode of restraint or seclusion. The debriefing occurs as soon as is possible and appropriate but no longer than 24 hours after the episode. The debriefing is used to: identify what led to the incident and what could have been handled differently; ascertain that physical and psychological well-being and right to privacy were addressed; counsel the individual for any trauma; when indicated, modify the individualís treatment plan.

Family & Guardian Notification

If the resident is a minor as defined in this subpart: (a) the facility must notify the parent (s) or legal guardian (s) of the resident who has been restrained or placed in seclusion as soon as possible after the initiation of each emergency safety intervention. (b) The facility must document in the residentís record that the parent (s) or legal guardian (s) has been notified of the emergency safety intervention, including the date and time of notification and the name of the staff person providing the notification.

No Requirement

Notification as soon as possible, no later than within 24 hours

Immediate notification when mechanical restraint or seclusion are used. Notification documented in the case record.

The individualís family is notified promptly of the initiation of restraint or seclusion. In all cases in which the individual has consented to have the family kept informed regarding his or her care and the family has agreed to be notified, staff promptly attempts to contact the family to inform them of the restraint or seclusion episode. The individual/family is informed of R&S policy.

Notification of Rights and Restraint and Seclusion Policies and Procedures at admission.

At admission the facility must; inform both the incoming resident and, in the case of a minor, the residents parent (s) or legal guardian (s) of the policy regarding the use of restraint or seclusion during emergency safety situations that may occur while the resident is in the program. Communicate its restraint and seclusion policy in a language that the resident, or his or her parent (s) or legal guardian (s) understands (including American Sign Language, if appropriate) and when necessary, the facility must provide interpreters or translators. Obtain an acknowledgement, in writing, from the resident, or in the case of a minor, from the parent (s) or legal guardian (s) that he or she has been informed of the facilityís policy on the use of restraint or seclusion during an emergency safety situation. Staff must file this acknowledgement in the residentís record. Provide a copy of the facilityís policy and, in the case of a minor, to the residentís parent (s) or guardian (s). Contact Information: The Facilityís policy must provide contact information, including the phone number and mailing address, for the appropriate State Protection and Advocacy organization.

Policy on rights notification but not specific to policy and procedure regarding the use of restraint and seclusion.

Explanation to the child and parent/guardian of the rules and expectations of the provider, as well as behavior management practices used (in own language); opportunity to view time-out and quiet rooms; demonstration of restraint procedures used by the provider.

At admission, written notification, documented in case record, that such interventions are used.

The initial assessment of each individual at the time of admission or intake assists in obtaining information about the individual that could help to minimize the use of restraint and seclusion. The initial assessment identifies; techniques to regain control; the individuals need for tools to manage his or her own aggressive behavior; pre-existing medical conditions or physical disabilities that would place the individual at greater risk; any history of physical or sexual abuse that would place the individual at higher psychological risk if restrained or secluded.

Training

The facility must require staff to have ongoing education, training and demonstrated knowledge of;

Techniques to identify staff and resident behaviors events and environmental triggers that may trigger emergency safety situations, the use of non-physical safety interventions, and the safe use of restraint and the safe use of seclusion including the ability to respond to signs of physical distress, certification in CPR,

Training provided by individuals who are qualified by training, education, and experience; training must include exercises in which staff are required to demonstrate in practice the techniques they have learned; staff must be trained and demonstrate competency before participating in interventions; staff must demonstrate their competencies as specified in paragraph a (Preventative and Safety Techniques) on a semi-annual basis and their competencies as specified in paragraph b (CPR) on an annual basis. Facility must document in personnel records that training and demonstration of competency were successfully completed. Documentation must include the data training was completed and person certifying competency. All training materials must be available for CMS review.

All staff that has direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of restraints and seclusions.

During orientation and ongoing training, all personnel should be made aware of the philosophy, rules, policies, procedures, intervention modalities used, and the provider's expectations for everyone who is working with children.

A certified trainer who has completed a recognized and professionally developed training program should conduct crisis prevention and management training.

Staff should be held to a competency level of performance in order to use restrictive procedures.

Ongoing refresher training should be provided to all caregivers.

All caregivers should be trained in First Aid and CPR and should be knowledgeable about any medical conditions unique to the individuals in their care that prohibit the use of physical intervention

Application of behavior management interventions by any person other than trained, qualified staff is prohibited.

All personnel receive initial and ongoing competency based training, including 4 - 12 hours depending upon position and client contact.

All direct service personnel receive behavior management training that includes: recognizing conditions that may lead to crisis, understanding how staff behavior may influence behavior of persons served, and appropriate methods for de-escalation.

Personnel who are designated to use restraint and seclusion "receive additional training that includes: the proper and safe administration and use of permitted techniques, understanding how a person experiences being placed in" seclusion or restraint, and "self-protection techniques."

"Training for persons authorized to conduct assessment and evaluation" includes assessing: physical and mental status, including signs of distress, nutritional and hydration needs, "readiness to discontinue use of the intervention, and recognizing when other medical or emergency personnel are needed."

Staff is trained and competent to minimize the use of restraint and seclusion and in their safe use. See intent of TX.3.2. training is to cover underlying causes of behavior, aggressive or threatening behavior caused by physical or medical condition, how staff behavior impacts children, use of de-escalation

Recognizing sign of physical distress.

Training in safe use of restraint and holding techniques, taking vital signs, nutrition/hydration needs, circulation and range of motion, hygiene and elimination,

Physical and psychological status, helping individuals meet criteria for discontinuation, recognizing readiness for discontinuation, when to contact medical staff or emergency staff

Those given authority to initiate should be trained to recognize how age, developmental considerations, gender, ethnicity and personal history may affect the way an individual responds to R&S. Also the use of behavior criteria from the discontinuation of R&S and how to help individuals meet those criteria.

Documentation

For each order, documentation must include: 1) name of the physician, 2) date and time the order was obtained, 3) the emergency safety intervention and length of time of order, 4) the time the emergency safety intervention began and ended, 5) The time and results of any 1 hour assessments, 6) The emergency safety situation that required the resident to be restrained or secluded, 7) the name, title, and credentials of staff involved in the emergency safety situation.

 

Critical incident documentation should include at minimum:

1) description of what happened, 2) date and time of occurrence, 3) intervention used reasons for use, and the duration of the intervention, 4) children involved, 5) caregivers or others involved, including full names, titles and relationship to child, 6) witnesses to the incident, 7) person making the report, 7) any injury to the child, including body chart or photo, 8) action taken by the provider, 9) preventive actions to be taken in the future, 10) follow-up required, 11) documentation of supervisory and administrative reviews.

The person's case record must include documentation of each episode. Logs must be maintained documenting names, reasons for restraint/seclusion/isolation, duration of intervention, and verification of continual monitoring.

Clinical/case records document that the use of restraint or seclusion is consistent with organization policy. The record documents: 1) individual/family informed of R&S policy and procedure, 2) pre-existing conditions that might impact R&S, 3) hx of physical or sexual abuse

For each episode, documentation of the following:

Circumstances that led to their use, consideration or failure of non-physical interventions, rationale for intervention selected, family notification when approp., written orders for use, behavior criteria for discontinuation, informing individual of beh. Criteria, each verbal order received, each in-person evaluation, 15 minute assessments of status, assistance provided to meet behavior criteria, continuous monitoring, debriefing with staff, injuries received and treatment provided, any deaths. Documentation allows for QI processes.

Reporting

Attestation of Facility Compliance Ė must be signed by facility director.

Reporting of Serious Occurrences Ė Facility must report each occurrence to the State Medicaid Agency and The Office of Protection and Advocacy. Serious occurrences include death, serious injury, and suicide.

Reports must be made by the close of the next business day after the occurrence. In the case of a minor the facility must notify the residentís parent (s) or guardian (s) as soon as possible and in no case more than 24 hours after the occurrence. Staff must document that it was reported to both the State Medicaid Agency and OPA. A copy of the report must remain in the record as well as in the incident and accident report logs. Deaths must also be reported to CMS Regional Office. Staff must document the reporting of the death to CMS.

 

Critical incidents involving restraint and seclusion that result in injury to a child or caregiver should be reported in writing to the regulatory agency by the end of the next business day.

Must be reported immediately to the chief executive officer or designee.

Clinical leadership is informed of instances in which individuals experience extended, or multiple episodes of restraint and seclusion.

R&S more than 12 hours

2 or more episodes of R&S within 12 hours, leadership notified every 24 hours if either condition continues.

Must report Sentinel Events including deaths, and serious injuries resulting in major permanent loss of function.

Quality Improvement

No Standards

 

All incidents of restraint and seclusion should receive administrative review.

Each provider should establish systems for tracking the frequency, location and type of incidents that occur. The data and management systems should have the potential to effectively monitor caregiver, child and programmatic involvement in critical incidents. This documentation and monitoring system allows the provider to review incidents and make decisions about individual and organizational practice.

Extensive CQI standards. The following apply specifically to behavior management: the organization evaluates annually how organizational practices compare with current best practices. "The organization reports quarterly to the governing body on the use of such practices."

Each incident of restraint, seclusion or isolation is administratively reviewed within 24 hours of the incident.

Extensive QI Standards but the following specifically applies to Restraint and Seclusion.

The organization collects data on the use of restraint and seclusion in order to monitor and improve its performance of processes that involve risks or may result in sentinel events.

Data collected by 1) shift, 2) length of episode, 3) date and time of initiation, 4) day of the week, 5) type of restraint, 6) injuries to staff or patient, 7) age, 8) gender, 9) multiple instances within 12 hour period, 10) number of episodes per individual, instances beyond 12 hours, use of medications as an alternative.

References

O.C.G.A. 290-2-5.14

HCFA Hospital Conditions of Participation Ė Special Conditions Ė Patient Rights

CMS Ė Title 42 Public Health Ė Chapter IV Ė Centers for Medicare and Medicaid Services, DHHS, Part 483 Ė Requirements for State and Long Term Care Facilities Ė Subpart G

Child Welfare League of America - CWLA Best Practice Guidelines for Behavior Management

COA 7th edition Standards and Self-Study Manual

JCAHO 2001-2002 Comprehensive Accreditation Manual for Behavioral Health Care

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