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PENNSYLVANIA |
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Standard or Definition |
PENNSYLVANIA CODE
Chapter 13. Use of Restraints in Treating Patients/Residents Authority
The provisions of this Chapter 13 issued under sections 201(2) and (8) and 202 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. § § 4201(2) and (8) and 4202); and sections 105, 112, and 113 of the Mental Health Procedures Act (50 P. S. § § 7105, 7112 and 7113), unless otherwise noted.
Source
The provisions of this Chapter 13 adopted October 28, 1977, effective November 28, 1977, 7 Pa.B. 3199, unless otherwise noted.
Cross References
This chapter cited in 55 Pa. Code § 5100.15 (relating to contents of treatment plan).
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Restraint Definition |
Restraints include devices and techniques designed and used to control acute or episodic aggressive behavior or involuntary movement of patients/residents.
Restraints do not include general protective security measures adopted in various institutions, including locked wards; special security measures adopted in Youth Development Centers and Youth Forestry Camps, maximum security State hospital or forensic units in State mental hospitals; or specific security measures ordered by a court.
Restraints can be classified according to the method used to control behavior as:
- Mechanical restraints.
- Chemical restraints.
- Seclusion.
- Exclusion.
- Psychological restraints.
Restraints may also be classified based on whether they are designed to control one of the following:
- Involuntary movement or lack of muscular control due to organic causes or conditions.
- Acute or episodic aggressive behavior.
Mechanical restraints.
Definitions. Mechanical restraints used to control acute or episodic aggressive behavior include anklets, wristlets, camisoles, muffs, mitts with lock buckles, wrist straps, head straps, restraining sheets and other similar devices.
Procedures.
- Qualified mental health professional staff designated by the Superintendent/Director may order use of mechanical restraints for a period not to exceed 2 hours. A physician shall be promptly notified. This initial order may not be renewed or extended by anyone before a physician examines the patient prior to doing so.
- A patient's/resident's treatment plan should indicate to the extent possible which physical restraints may and may not be utilized in an emergency and should call attention to possible physical problems which should be monitored. A patient/resident who is subject to mechanical restraints should be checked at least every 15 minutes by staff. Physical needs shall be met promptly.
- Opportunity for movement or exercise shall be provided for a period of not less than 10 minutes during every 2 hours in which the restraints are employed.
- The patient's/resident's chart shall document that this subsection has been followed.
Exclusion. [Note: This is terminology for time out] Within mental health/mental retardation facilities the removing of the patient/resident from his immediate environment and restricting him to another area.
Exclusion shall only be employed when it is clearly documented that another less restrictive method has been unsuccessful in controlling the unacceptable behavior.
Exclusion shall be limited and documented as a therapeutic technique in the resident's individual treatment plan.
In mental health facilities children under the age of 14 requiring seclusion or exclusion shall be continuously monitored within or just outside the exclusion area by mental health personnel, and the room may not be locked or otherwise secured. Soft inanimate objects shall be made available to the patient to permit the venting of aggression.
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Restraint Exclusions |
Restraints shall be employed only when necessary to protect the patient/resident from injuring himself or others, or to promote normal body positioning and physical functioning.
Restraints shall not be employed as punishment, for the convenience of staff, as a substitute for program, or in any way that interferes with the treatment program. Restraints shall not be applied unless other available techniques or resources have failed, and the least possible restrictions shall be used.
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Chemical Restraint Definition |
Definition: Chemical restraint shall mean the use of drugs or chemicals for the specific and exclusive purpose of controlling acute or episodic aggressive behavior by a patient/resident.
Exclusion: Drugs administered on a regular basis, as part of the treatment plan and for the purposes of treating the symptoms of mental, emotional or behavioral disorders and for assisting the patient/resident in gaining self control over his impulses, are not to be considered chemical restraints.
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Seclusion Definition |
The placement of a patient/resident in a locked room may be used as a therapeutic technique only. |
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Seclusion Exclusions |
The patient's/resident's request to spend time in a private unlocked room is not to be considered seclusion and shall be granted if feasible and not therapeutically contra indicated. Quarantine or other preventive health measures are not considered seclusion.
Seclusion as defined in this paragraph may not be employed in State center for the retarded. |
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Criteria for Restraint and Seclusion |
Restraints
Restraints shall be employed only when necessary to protect the patient/resident from injuring himself or others, or to promote normal body positioning and physical functioning.
Individual program plans, developed for patients/residents in accordance with applicable statutes and regulations, shall have goals and methods aimed at treating and eliminating behavior necessitating the use of restraints. Efforts shall similarly be made by employees to reduce the need for restraints by utilizing therapeutic approaches such as goal planning aimed at redirecting and releasing aggression through healthy channels, counseling, and withdrawing a patient/resident from an overstimulating environment.
A patient's/resident's treatment plan should indicate to the extent possible which physical restraints may and may not be utilized in an emergency and should call attention to possible physical problems which should be monitored.
Use of restraints to control acute or episodic aggressive behavior.
General policy. Restraints designed to control acute or episodic aggressive behavior of patients/residents shall be employed only in accordance with the procedures and standards set forth in subsection b.
Individual program plans shall attempt to treat the behavior necessitating the use of restraints. Employees shall attempt to prevent this behavior by recognizing indications of impending behavior and intervening in a positive, constructive manner to prevent hyperactivity or assaultiveness.
Standards. (subsection b)
Restraints shall be used to control acute or episodic aggressive behavior when a patient/resident is acting in a manner as to be a clear and present danger to himself, to other patients/residents, or to employees, and only when less restrictive measures and techniques have proven to be or are less effective.
The use of restraints, the conduct necessitating the restraint, and alternative methods which were unsuccessful in controlling the behavior shall be noted in the patient's/resident's chart. The monitoring of patients/residents under restraint shall be recorded in the chart.
Seclusion
Seclusion shall be used only under the following conditions:
- When necessary to protect the patient/resident or others from physical injury.
- To decrease the level of stimulation when a patient/resident is in a state of hyperactivity.
- When less restrictive measures and techniques have proven ineffective.
- Seclusion as defined in this paragraph may not be employed in State center for the retarded.
The following procedure is to be followed when a patient/resident is in seclusion:
Potentially dangerous articles will be removed from the patient/resident. This includes articles of clothing if there are reasonable grounds to believe such clothing constitutes a substantial threat to the health or safety of the patient/resident or others.
The patient/resident will be checked at no less than 15-minute intervals by personnel.
The physical needs of the patient/resident will be given prompt response.
In mental health facilities if a patient/resident in voluntary treatment requires seclusion, will not consent to such and requests to be discharged, this request shall be granted unless the procedures and standards of section 302 of the Mental Health Procedures Act (50 P. S. § 7302) regarding emergency involuntary treatment and § 5100.76 (relating to notice of withdrawal) are followed. Similarly, the procedures of section 405 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. § 4405) shall be followed for mentally retarded persons who have been voluntarily admitted, require seclusion, and request to be discharged.
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Monitoring Requirements |
Seclusion
In mental health facilities children under the age of 14 requiring seclusion shall be continuously monitored within or just outside the seclusion area by mental health personnel, and the room shall not be locked or otherwise secured. Soft inanimate objects shall be made available to the patient to permit the venting of aggression
The patient/resident will be checked at no less than 15-minute intervals by personnel.
Note: assume this is for patient/resident age 14 or older
The physical needs of the patient/resident will be given prompt response.
Restraint
The monitoring of patients/residents under restraint shall be recorded in the chart.
Note: No monitoring standard indicated
Mechanical Restraint
A patient/resident who is subject to mechanical restraints should be checked at least every 15 minutes by staff. Physical needs shall be met promptly.
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Ordering and Initiation |
Restraint
The Superintendent/Director is administratively responsible for insuring that restraints are imposed only in accordance with this chapter. The Superintendent/Director is responsible for insuring that employees shall know specific procedures, methods and steps to follow in instituting this chapter and that they are familiar with this chapter and the criteria for their application.
Seclusion
In the case of mental health facilities, authority for seclusion of a patient/resident rests with the Director or his designee.
In mental retardation facilities, authority for exclusion rests with the qualified mental retardation professional.
In the case of Youth Development Centers, Youth Forestry Camps and all other Departmental institutions authority for seclusion rests with the Superintendent/Assistant Superintendent.
Normally, written orders shall precede the placement of a patient/resident in seclusion or exclusion. In emergencies, telephone orders may be accepted, but an order shall be properly countersigned within the time specified by the institution. In no case, however, shall this period exceed 24 hours.
An order for seclusion or exclusion is good for only 24 hours. The time the order is received shall be recorded with the order on the order sheet.
In mental health/mental retardation facilities, telephone orders are not acceptable for continued seclusion or exclusion. The patient/resident shall be seen by a physician within 24 hours, and the order shall be rewritten and supported by a progress note.
In Youth Development Centers and Youth Forestry Camps, the resident/patient must be seen by the Superintendent/Assistant Superintendent who will assess the resident's/patient's needs and seek professional consultation if indicated.
In the absence of a written or telephone order, a patient/resident may be placed in seclusion or exclusion as a protective measure for no more than 1 hour when the action is immediately necessary.
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In-person Assessment |
In mental health/mental retardation facilities, if the nursing supervisor/designated program specialist, after visiting the patient/resident, deems seclusion or exclusion necessary, the attending physician or his delegate shall be notified immediately.
In Youth Development Center or Youth Forestry Camp facilities, if the designated program specialist, after visiting the patient/resident, deems seclusion necessary, the Superintendent/Assistant Superintendent shall be notified immediately.
In mental health/mental retardation facilities, telephone orders are not acceptable for continued seclusion or exclusion. The patient/resident shall be seen by a physician within 24 hours, and the order shall be rewritten and supported by a progress note.
In Youth Development Centers and Youth Forestry Camps, the resident/patient must be seen by the Superintendent/Assistant Superintendent who will assess the resident's/patient's needs and seek professional consultation if indicated.
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Debriefing |
None indicated
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Family & Guardian Notification |
None indicated |
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Notification of Rights and Restraint and Seclusion Policies and Procedures at admission |
None indicated
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Training |
Restraint
Each institution must prepare a restraint plan describing specific procedures for use by employees in implementing this chapter. The plan must be submitted through the appropriate Regional Deputy Secretary and Regional Program Commissioner for approval by the Executive Deputy Secretary and appropriate program Deputy Secretary.
Each plan shall specifically describe a restraint training program including refresher courses to be offered to employees working with patients/residents. The plan must also include a procedure for monitoring the implementation and application of this chapter. A specific individual or committee may be designated for this purpose.
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Documentation |
The use of restraints, the conduct necessitating the restraint, and alternative methods which were unsuccessful in controlling the behavior shall be noted in the patient's/resident's chart. The monitoring of patients/residents under restraint shall be recorded in the chart.
Concise and informative written reports concerning the status of the patient/resident will be prepared and retained in the record of the patient/resident in seclusion or exclusion. Daily written reports concerning patient/residents in seclusion or exclusion shall be prepared and sent to appropriate designated staff of the facility. These reports shall include information as follows:
- Identifying data concerning name, age, location in building and record number of patient/resident.
- Reason for seclusion or exclusion.
- Period of time in seclusion or exclusion.
- Brief statement regarding status of patient/resident.
- Record of time given for attention to personal needs.
In facilities, the nursing supervisor or designated program specialist shall document his observations fully on an appropriate progress report.
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Reporting |
If a patient/resident is placed in seclusion or exclusion as an emergency procedure, the unit program supervisor or appropriate designated program specialist of the area shall be notified immediately.
In mental health/mental retardation facilities, if the nursing supervisor/designated program specialist, after visiting the patient/resident, deems seclusion or exclusion necessary, the attending physician or his delegate shall be notified immediately.
In Youth Development Center or Youth Forestry Camp facilities, if the designated program specialist, after visiting the patient/resident, deems seclusion necessary, the Superintendent/Assistant Superintendent shall be notified immediately.
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Quality Improvement |
Restraint
Each institution must prepare a restraint plan describing specific procedures for use by employees in implementing this chapter. The plan must be submitted through the appropriate Regional Deputy Secretary and Regional Program Commissioner for approval by the Executive Deputy Secretary and appropriate program Deputy Secretary.
The plan must also include a procedure for monitoring the implementation and application of this chapter. A specific individual or committee may be designated for this purpose.
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