OPERATING PROCEDURE Florida State Hospital s1

OPERATING PROCEDURE Florida State Hospital NO. 150-14 Chattahoochee, Florida November 10, 2010

Health

MEDICAL RESTRAINTS AND SAFETY DEVICES

1. Purpose: This operating procedure prescribes the use of medical restraints at Florida State Hospital. It establishes guidelines and methods to be employed by Hospital staff in restraining residents when the need is of a medical nature.

2. Scope: This procedure applies to all units at Florida State Hospital which use medical restraints.

3. Training Requirements: Physicians, Advanced Registered Nurse Practitioners, and nurses will be trained on this operating procedure upon hire into the position during Worksite Education and by their supervisor each time the operating procedure is revised.

4. References:

a Florida Statutes, Chapter 394.

b. Florida Administrative Code 59A-3, Hospital Licensure.

c. Restraint Proper Environment OBRA Restraint Guidelines.

d. State Operations Manual Provider Certification #241, 1990.

5. Definitions:

NOTE: Definitions and examples of situations which are not considered restraint have been separated from those which will be considered restraint for clarity. A medical restraint will be used to increase a resident's level of independence (enabler), to prevent involuntary self-injury and for medical symptoms of a life threatening nature which require treatment.

A documented mental status exam or other standard assessment should be used to support the team's decision that a resident's prognosis for change of behavior using behavioral intervention is poor.

a. The following will be considered restraints:

(1) Medical restraints are used as enablers to promote greater functional independence. An example is when a resident who may be confined to bed is able to sit in a chair with a restraint such as a posey vest for support of body parts.

(2) Medical restraint is the containment or restriction of the movement of a resident when the cause of the behavior, as assessed by the recovery team is of a medical nature and

This Operating Procedure supersedes: Operating Procedure 150-14, dated August 28, 2009 Office of Primary Responsibility: Health Care Medical Service Director Distribution: Florida State Hospital Computer Network Users Operating Procedure 150-14 November 10, 2010 cannot be changed by behavioral programming. One possible example is when a resident is required to have complete bed rest due to an illness/surgery, but cannot cognitively understand the medical need for complete bed rest. Another example is the use of restraint to maintain a resident in isolation to prevent the spread of a communicable disease when the resident will not independently maintain isolation.

(3) Medical restraint can be used with residents who cannot cognitively understand the medical implication of their health status. Restraint may be used to assure the resident does not remove feeding tubes, intravenous tubes, oxygen catheters, Levin tubes, tracheostomy tubes, gastrostomy tubes, sutures, casts, splints, etc.

(4) Medical restraints can be used when deficits in health status, sensory/ perceptual functioning, mobility functioning or cognitive functioning for which the treatment staff agree the risk of injury outweigh the benefit of the resident's freedom of movement. Some examples include:

(a) residents who may walk until they become exhausted or wander aimlessly and disturb other residents which puts them at risk for bodily injury; resident assessment must indicate that cognitive assessment does not indicate good potential for behavioral training;

(b) residents who are diabetic and take food from other resident's trays during mealtime;

(c) residents who wander at mealtime and will not/can not sit down for a sufficient period of time to assure adequate dietary intake;

(d) ambulatory residents who the team has assessed the risk/benefit of use of restraint and determined the resident requires some restriction of spastic/involuntary movements;

(e) residents who are ambulatory but require temporary use of a geriatric chair and table top or posey;

(f) residents who require restraint during completion of activities of daily living (ADL) when the resident's cognitive condition is chronic (Alzheimer’s, organic brain syndrome) and cannot be changed by behavioral programming;

(g) residents who get out of bed at night without assistance and are at high risk for falls.

b. Safety devices will not be considered restraints. These devices should be used unless the attending physician feels they are contraindicated, in which case an order will be written discontinuing use. Each recovery team should review the use of safety devices and potential contraindications for use at regularly scheduled recovery team meetings (30, 60, 90 day cycles). Examples of safety devices are:

(1) Stretcher belts, one-piece safety belts, safety belts, and transportation safety belts intended for use to prevent a resident from accidentally falling from a stretcher, physical therapy equipment, shower chair, bedside commode, wheelchairs are NOT medical restraints. Seat belts in a car, van or other vehicle are safety devices.

2 Operating Procedure 150-14 November 10, 2010

(2) Orthopedic appliances such as braces, traction, and casts are not restraints. They are used to assist the resident in obtaining and maintaining maximum healing.

(3) The use of a gerichair without a tabletop for a resident who requires assistance with ambulation is not considered a restraint. The use of a gerichair with or without a tabletop for a non-ambulatory resident is not considered a restraint. In these instances, a gerichair serves as a physical support to prevent the resident from accidentally injuring him/herself.

6. Philosophy: It is the philosophy of Florida State Hospital that the medical restraint of residents are methods of last resort and should not be used unless lesser restrictive methods of intervention have been or would be ineffective. Residents will be fully evaluated for restraint elimination and/or reduction at the time of each recovery team review (30, 60, 90 day) and at the time of the 180-day review. Lesser restrictive methods include, but are not limited to; pillows, pads and removable lap trays. Medical restraints shall be applied/ utilized in a manner that is most comfortable to the resident and protects the resident's dignity.

a. Medical Restraints and safety devices shall not:

(1) impair neurovascular integrity;

(2) impair respiration;

(3) be tied to bedrails or moving parts of a gerichair or wheelchair;

(4) prevent residents from eating comfortably;

(5) interfere with toilet needs;

(6) interfere with bathing, dressing changes, or other hygiene needs;

(7) prevent immobile residents from being repositioned every two hours;

(8) impair skin integrity (i.e., cause bruises, etc.);

(9) be used for the convenience of staff;

(10) be used as punishment;

(11) be used as aversive stimulus.

7. Requirements: Prior to using restraint, less restrictive measures than restraint, such as pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented.

When this is a temporary problem it shall be so entered on the Temporary Medical/Other Service Needs form, but if written for a period of a month, it will be entered on the Ongoing Issues list.

a. Restrictions: Medical restraints shall be used only when clinically indicated to:

(1) protect the resident from self injury;

(2) facilitate the rendering of necessary medical treatment such as, nasogastric feeding or the elevation of an extremity;

(3) act as an enabler to increase the resident's level of independence;

(4) to prevent the exacerbation of an existing medical condition;

(5) facilitate the prevention of the spreading of a communicable disease.

b. Resident's Rights: Assurance that the resident's safety, dignity, and civil liberties have been maintained must be made by the highest level supervisor present, each time medical restraints are utilized. The use of the restraining device must first be explained to the resident and documented in the progress notes.

Staff should communicate to resident before and during application of medical restraints, in order to reduce resident's distress or anxiety.

c. Orders: As part of the Recovery Plan, the attending physician shall write the order for medical restraint after a clinical assessment of the situation. The assessment, and the rationale for the use of medical restraint, shall be included in the progress notes. The resident treatment order shall specify the conditions under which the resident is to be restrained, the type of restraint to be used, and the exact duration of restraints. In the event the condition of the resident is such that he/she should be observed more frequently than every two (2) hours, the physician shall order the frequency of observation. Medical restraint orders are valid for up to seven (7) days, at which time they must be rewritten if clinically indicated.

If, however, the condition of the resident is chronic and relatively stable, then the requirement is reduced. In such cases, the duration of the order can last for up to one (1) month, at which time the order must be rewritten. These restraints will be considered extended medical restraints.

d. Emergency Medical Restraints: The physician and/or the nurse has the authority to utilize emergency medical restraints.

e. Observations: An observation of the restrained resident is to be made every two (2) hours, or more frequently if ordered by the physician, during the duration of restraint by the direct care staff assigned. An registered nurse/licensed practical nurse shall assess the resident shortly after the shift and approximately four (4) hours later.

f. Care of the Resident: All efforts will be made to ensure the physical comfort and safety of the resident while he/she remains in restraints. Efforts shall be documented on the flow sheet and include:

(1) Exercise and Repositioning: During each two-hour period, active or passive exercises and repositioning will be provided unless contraindicated.

(2) Meals: Residents will receive all meals at regular times. Residents will be positioned and restraints adjusted in order for meals to be eaten both safely and comfortably. (3) Toileting: Residents will be allowed to toilet themselves in the most normal manner possible. Toileting will be allowed upon request, but will be offered during each one- hour period. If the resident is incontinent, care will be provided at each time of need.

(4) Bathing: Baths will be provided based on the resident's condition.

g. Flow Sheets: A Medical Restraint Flow Sheet will be maintained by the direct care staff during the entire period that the resident is in restraints. The supervisor will check the flow sheet to assure it is being completed correctly.

h. Recovery Team Responsibility: The recovery team is to review the need for medical restraints as part of their total management of the resident, during scheduled team meetings (30, 60, 90 day cycle). The team will assure that adequate positioning interventions, and other specific individual interventions, are included in the Recovery Plan. Reduction plans as well as regular attempts/evaluations without restraint will be incorporated into the plan. Plans to reduce restraints shall include specific instruction and time frames for reduction.

i. Physician Documentation:

(1) The physician will document the rationale for the restraint order on the Physician's Order form or in the progress note section of the record.

(2) The Initial Progress Note by physician will contain:

(a) a description of the behavioral and clinical assessment of the resident which prompted the decision to restrain;

(b) the precise goals of restraint;

(c) the condition for discontinuing the restraint.

(3) Monthly Progress Note: The physician will write monthly progress notes for all residents with orders for medical restraints. The note will describe, assess and justify the requirement for, and the effects of, the restraint used.

(4) The physician will review, initial and date all consultations (Form 29) related to restraint usage.

j. Licensed Nurse/Shift Supervisor Documentation:

(1) Emergency Restraints: The nurse will assess the resident within 30 minutes after the restraint is authorized /applied and document his/her findings on the Medical Restraint Nursing Assessment/Progress Note (Form 617) (see Attachment 1). The resident will be assessed/documented at the beginning of each shift and approximately four hours later for the duration of the order.

(2) All residents in medical restraints shall have documentation which indicates they were observed by an RN/LPN shortly after the beginning of the shift and approximately four (4) hours later. The assessments will be recorded on the Medical Restraint Nursing Assessment/Progress Note (Form 617). This form should be filed in the chronological progress note section of the chart.

(3) The assessment form will be required for all residents in medical restraint regardless of the duration of the restraint.

(4) Monthly Progress Note: The nurse will assess those residents who require restraint for chronic conditions every thirty days prior to the order being rewritten. For example, 5 Operating Procedure 150-14 November 10, 2010 a resident who wanders aimlessly and will not sit long enough to assure adequate dietary intake thus requires mealtime restraint. This monthly assessment of the management of the situation and the resident's condition will be continued throughout the duration of the condition. The assessment will include information pertaining to the resident's trials out of restraint, physical, mental, psychosocial, and functional status (i.e., Has the use of restraints been associated with the following: falls, decline in functioning such as chronic constipation, urinary incontinence, skin break down, loss of independent mobility, increased agitation, loss of balance, symptoms of withdrawal?).

k. Direct Care Documentation: Direct care documentation will be completed at least every two (2) hours on the Medical Restraint Flow Sheet, Florida State Hospital Form 69 (Attachment 2). The flow sheet will be reviewed for completion by the nurse at the time he/she assesses the resident.

l. 180 Day Review: The Clinical Unit Management Team will review each resident who is placed in extended medical restraints at least every 180 days. One review will be done at the time of the annual physical exam or in six (6) months, whichever comes first. This process should cycle to coincide with the annual physical. The review will include the reason the extended medical restraint is necessary. Efforts to reduce the level of restriction of the restraint and efforts to discontinue the restraint should be discussed and documented. The documentation of the review shall be done on Florida State Hospital Form 29 (Consultation Referral Report). The referral section of the form shall be completed by the recovery team leader. They will be returned to the physician for review, initials and signature.

m. Data Input: Unit Administrator will assign responsibility for entering all occurrences of medical restraints into the Hospital Central Computer. This input will be done no less than monthly by the first workday of the month for the previous month. New restraint orders will be entered as they occur.

(Signed original on file in Central Health Information Services)

DIANE R. JAMES 2 Attachments Hospital Administrator 1. Medical Restraint Nursing Assessment/ Progress Note (Form 617) 2. Medical Restraint Flow Sheet (Form 69)

SUMMARY OF REVISED, ADDED, OR DELETED MATERIAL Deletes reference to medical restraints in U31 as automatically safety devices.

6 Shift: ______Type Restraint: ______Date: Response to Restraint: Resident’s General Condition: Deviation from Normal:

Resident was checked and Medical Restraint Flow Sheet reviewed at beginning of shift and four hours into shift. Yes _____ No _____ (Requires comments) Comments:

Signature and Title:

Shift: ______Type Restraint: ______Date: Response to Restraint: Resident’s General Condition: Deviation from Normal:

INSTRUCTIONS: Licensed Nurse will complete form for ADDRESSOGRAPH: each shift. Emergency Medical Restraints require documentation thirty (30) minutes of application. Refer to Operating Procedure 150-14, “Medical Restraints and Safety Devices.”

File in chronological order in daily Progress Notes in the ward chart. Unit ______** CONFIDENTIAL & PRIVILEGED INFORMATION ** FOR PROFESSIONAL USE ONLY ** FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL 32324 Form 617, (Updated) Apr 97 FLORIDA STATE HOSPITAL MEDICAL RESTRAINT Office of Primary Responsibility: Health Care Services Medical Service Director NURSING ASSESSMENT/ Attachment 1 PROGRESS NOTE Operating Procedure 150-14 Dr.’s Orders and Restraint Code: ______

Date ______Time

Time in/Employee Initial Time Out/Employee Initial Document Type Restraint--Select from Restraint Code as Indicated CARE PROVIDED: If on BB or Toileting Offered Continent Voided (Number) Bowel Movement (Number) Meals (record % Eaten [100%, 75%, 50%, 25%, 0%]) Fluids (Record cc’s Taken) Bath Restraints Released Exercised Repositioned (Use Code) PHYSICAL ASSESSMENT: Calm Agitated Breathing Normal Abnormal Skin Temperature and Color Normal Abnormal Vital Signs Taken & Time (each shift) BP/TPR 24 Hour Fluid Intake Total at End of Night Shift: SIGNATURE & TITLE INIT. SIGNATURE & TITLE INIT. SIGNATURE & TITLE INIT.

INSTRUCTIONS: Direct care staff will complete. Document with ADDRESSOGRAPH: employee initials or as indicated in appropriate space a minimum of q 2 hrs. Asterisk (*) any condition reported to nurse. If restraints limited to less than 2 hrs., use time in/out spaces indicated. Refer to Operating Procedure 150-14, “Medical Restraints and Safety Devices.”

File in the Flow Sheet section of the ward chart.

Restraint Code 1: Restraint Code 2: Repositioning Key: V - Vest L - Left B/L - Bed/Left Side W - Waist R - Right B/R - Bed/Right WR - Wrist B - Bed B/B - Bed/Back M - Mitten C - Chair ST - Standing MP - Minipelvic S - Sitting GCT - Gerichair/Tabletop R - Reclining H - Houdini ** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY ** FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL 32324 Form 69, (Revised) Feb 99 FLORIDA STATE HOSPITAL MEDICAL RESTRAINT FLOW SHEET Office of Primary Responsibility: Clinical Director Attachment 2 Operating Procedure 150-14