Restraint and Seclusion Policy

Title: Restraint and Seclusion Policy Department/Service WHS-SYSTEMWIDE Line: Location: Document Location ID: Origination Date: 1/1996 Last Review 1/2015 Last Revision 12/2017 Date: Date: SCOPE This document applies to Wise Health System including Controlled Affiliates (“WHS”). DEFINITIONS When used in this document with capital letter(s), the following word(s)/phrase(s) have the meaning(s) set forth below unless a different meaning is required by context. Additional defined terms may be found in the WHS Policy and Procedures Definitions document. Behavioral Emergency- A situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive, de-escalating, or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain or seclude the individual to prevent: 1. Imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit suicide or inflict serious bodily harm; or 2. Imminent physical harm to others because of acts the individual commits Chemical Restraint- The use of a drug or medication to manage patient behavior or restrict freedom of movement to prevent danger to self or others and which is not a standard treatment or dosage for the patient’s condition. Competence- Demonstrated knowledge, skill, and ability Continuous face to face observation- An in-person line- of- sight that is maintained in an uninterrupted manner and is free of distraction Emergency medication- A psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency, when other interventions are ineffective or inappropriate Face-to-face- Describes a contact with an individual that occurs in person. Face to face does not include a contact made through the use of video or telecommunication conferencing or technologies, including telemedicine. Inappropriate psychiatric emergency- In no case may inappropriate designation of a situation as a “psychiatric emergency” be used to circumvent the process of obtaining consent or applying to the court for an order authorizing administration of psychoactive medication. Mechanical or physical restraint- Any device, material, or equipment that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely Medications used as “Standard of Care” 1. Used within pharmaceutical parameters by the FDA and the manufacturer 2. The use follows established and recognized national practice standards 3. Use of medication to treat a specific clinical condition based on that patients target symptoms, overall clinical situation, and MD’s knowledge of patient expected and actual response to medication Page 1 of 13 Restraint and Seclusion Policy [Enter Location] Expectation that the standard use of a psychotherapeutic medication to treat the patient’s condition enables the patient to be more effective or appropriately function in the world around him/her than would be possible without the use of medication. Non-violent, non-self-destructive behavior- Behavior related to a non-psychiatric medical condition or symptom that indicates the need for an intervention to protect the individual from harm. Personal restraint/hold- Any manual method by which a person holds or otherwise bodily applies physical pressure that immobilizes or reduces the ability of the individual to move his or her body or a portion of his or her body. Physically holding an individual during a forced administration of a psychoactive medication, including court ordered medication, constitutes a personal restraint/hold. (Maximum 15 minutes). This is a one-time order further restraint requires a physician order for each episode. Protective device- A device used to prevent injury or to permit wounds to heal. Psychiatric emergency--A situation in which, in the opinion of the physician, it is immediately necessary to administer medication to ameliorate (improve) the signs and symptoms of a patient's mental illness and to prevent: 1. Imminent probable death or substantial bodily harm to the patient because the patient: a. Is threatening or attempting to commit suicide or serious bodily harm; or b. Is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or 2. Imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits Psychoactive medication- Medication whose primary intended therapeutic effect is to treat or ameliorate (improve) the signs or symptoms of mental disorder, or to modify mood, affect perception, or behavior Refusal to consent to administration of psychoactive medication (refusal)--Actions which include the following behaviors: 1. The patient or legally authorized representative communicates orally, through sign language, or in writing that he or she refuses psychoactive medication. 2. The patient communicates through behavior that he or she refuses psychoactive medication, e.g., refusing to swallow oral medication or refusing to submit to hypodermic injection of psychoactive medication. 3. The patient pretends to swallow oral psychoactive medications, and the attending physician determines that the pretending behavior is due to an unwillingness to take the medication. 4. The patient gives either no response or a noncommittal response after he or she has received the standard risk-benefit explanation. Restraint- The use of any personal restraint/hold or mechanical restraint that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely. A drug or medication, when it is used as a restriction to manage the patient’s behavior, or restrict the patient’s freedom of movement is a restraint, not as a standard of care or dosage for the patient’s condition. Seclusion- The involuntary separation of an individual from other individuals for any period of time and or the placement of the individual alone in an area from which the individual is prevented from leaving. Being in a locked room or posting a security guard at the door that is preventing the patient from leaving is seclusion. Seclusion room- A hazard-free room or other area in which direct observation of an individual can be maintained and from which the individual is prevented from leaving. Supportive device- A device voluntarily used by an individual to posturally support the individual or to assist the individual who cannot obtain or maintain normal bodily function. Page 2 of 13 Restraint and Seclusion Policy [Enter Location] POLICY WHS ensures clinical justification of restraint use, while protecting patient rights, dignity and well-being. PROCEDURE Exclusions to policy: The following are not considered restraints and are not subject to the CMS, TAC, or TJC standards: 1. Limitation of mobility or immobilization for medical, dental, diagnostic, or surgical procedures, including post-procedure care 2. Adaptive support used in response to a patient’s need (i.e. postural support, ortho appliances) 3. Protective equipment, papoose boards, IV arm boards, hand mitts that do not limit movement of fingers and are not tied down 4. Gurney or bed rails used for sedated patients or for those experiencing involuntary movements or on seizure precautions 5. Use of 4 side rails on a bed in constant motion for improved circulation or prevention of skin breakdown 6. Side rails on stretchers 7. Forensic restrictions (handcuffs, shackles, or seclusion) imposed by correctional authorities. 8. Holding a child for medical reasons such as to giving an antibiotic shot, starting an IV, or doing a lumbar puncture 9. Methods used to permit the patient to participate in activities without the risk of harm i.e. walkers General Restraint Use 1. Family notification will be made as soon as feasible if patient consents to family being informed of condition. a. Family notification will be documented in the medical record. i. The date and time of the notification with the name of the staff member contacting the family and shall include any unsuccessful attempts made, the phone number called, and the name of the person with whom the staff member spoke b. Explain to the patient/family the plan and rationale for using restraints and the conditions/behaviors required for the release from restraints. 2. Modify plan of care when restraints are initiated, method is altered, or upon discontinuation of restraints a. The plan of care will reflect any use of psychoactive medication as part of an integrated treatment approach aimed at increasing the patient’s functioning and quality of life. 3. Restraints will be discontinued at the earliest possible time. At any time during the restraint or seclusion process, they may be discontinued by a RN, physician, or AHP/LIP should re-evaluation determine they are no longer necessary. a. Discontinuation is documented in the medical record including the circumstances under which restraint or seclusion is discontinued. 4. If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to reinitiating the use of restraint or seclusion. 5. Restraint or seclusion orders may not be written as “standing” or “prn”. 6. Apply the appropriate sized restraints snugly to the body part, but not tight enough to interfere with circulation or breathing. 7. When using a limb restraint, use a slip knot and fasten restraints to the bed frame, not to the side rails. 8. Place call light within reach of patient in restraints, when not in line of sight care 9. Hand-off communication, at shift change, will include information regarding the time of restraint or seclusion treatment was initiated, the current status of the patient’s physical, emotional and behavioral condition, and the specific criteria for release necessary for the patient to be removed from restraint or seclusion 10. Patients in restraints will have an environment that is free of hazards, adequately ventilated and appropriately lighted.

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