FLORIDA STATE STATE OF FLORIDA OPERATING PROCEDURE DEPARTMENT OF NO. 150-14 CHILDREN AND FAMILIES CHATTAHOOCHEE, April 26, 2017

Health

MEDICAL RESTRAINTS & SAFETY DEVICES

1. Purpose: This operating procedure prescribes the use of medical restraints and safety devices 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. 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, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for ,

e. Centers for Medicare & Medicaid Services, HHS. §482.13 Conditions of Participation: ’s Rights

4. Philosophy of Florida State Hospital: Medical restraints of residents are methods of last resort and shall not be used unless lesser restrictive methods of intervention have been attempted and determined to be ineffective. Residents will be fully evaluated for restraint elimination and/or reduction at the time of each recovery team review (monthly, bi-monthly, 6-months and annual) and at the time of the 180-day review. Medical restraints shall be applied/ utilized in a manner that is most comfortable to the resident while preserving his/her dignity.

Medical Restraints and safety devices shall NOT:

a. impair neurovascular integrity;

b. impair respiration;

c. be tied to bedrails or moving parts of a gerichair or wheelchair;

d. prevent residents from eating comfortably;

e. interfere with toilet needs;

This Operating Procedure supersedes: Operating Procedure 150-14 dated April 21, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Medical Services DISTRIBUTION: See Training Requirements Matrix April26,2017 FSHOP150-14

f. interfere with bathing, dressing changes, or other hygiene needs;

g. prevent immobile residents from being repositioned every two hours;

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

i. be used for the convenience of staff;

j. be used as punishment; or

k. be used as aversive stimulus.

5. Staff Training: Staff shall be trained by Professional Development and Training as part of orientation and subsequently on an annual basis. Staff responsible for the following actions will demonstrate competency in the following skills before participating in a , related assignment or in provision of care for a resident in medical restraint:

a. Observing for and reporting signs of physical and psychological distress.

b. Safe and appropriate use of medical restraint techniques and safe application of medical restraint devices.

c. Monitoring the physical and psychological well-being of the person who is restrained, including but not limited to respiratory and circulatory status, skin integrity, vital signs and any other associated requirements.

6. Requirements: Prior to using medical restraint, less restrictive measures, that include, but not limited to pillows, pads, and removable lap trays coupled with appropriate exercise will have been tried and documented.

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; for example the use of soft helmet for a resident with a seizure disorder if its purpose is to allow the resident some freedom of movement;

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

(5) serve as a preventive measure in the spread of a communicable disease.

b. Residents’ Rights: The resident's safety, dignity, and civil liberties must be top priorities each time medical restraints are utilized. Use of the restraining device must first be explained to the resident, and documented in the progress notes.

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

c. Physician’s 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

2 April26,2017 FSHOP150-14 the use of medical restraint shall be included in the progress notes. The resident’s treatment order shall specify:

(1) the conditions/medical rationale under which the resident is to be restrained;

(2) the type of restraint to be used; and

(3) parameters that determine the duration of restraints use.

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 continued use is necessary and clinically indicated.

If the condition of the resident is chronic but relatively stable, then the requirement for frequency of renewal of Physician’s Order may be reduced. For example, the duration of the order may 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 have the authority to utilize emergency medical restraints.

e. Observations: Generally, an observation of the restrained resident is to be made and documented every two (2) hours; but more frequently as ordered by the physician. A registered nurse shall evaluate the resident shortly after the shift and approximately four (4) hours later. This evaluation shall be documented in the progress notes. The LPN can observe, gather data, and report.

f. Care of the Resident: All efforts will be made to ensure the physical comfort, dignity 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 will be adjusted as necessary in order for meals to be eaten both safely and comfortably.

(3) Toileting: Residents will be allowed to toilet themselves in the most normal and dignified 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 medical restraints. It is the immediate supervisor’s responsibility to check the flow sheet to ensure it is being completed correctly.

h. Recovery Team Responsibility: The recovery team shall review the need for medical restraints as part of their total management of the resident. This is done during scheduled team meetings (monthly, bi-monthly, 6-months and annual 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.

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i. Physician Documentation:

The physician will document the rationale for the medical restraint order on the Physician's Order form.

(1) The physician will document in the Progress Note the following:

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

(b) the precise goals of medical restraint; and

(c) the condition for discontinuing the medical restraint.

(2) 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 medical restraint used.

(3) 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 Registered Nurse will assess the resident within thirty (30) minutes after the restraint is applied; and document his/her findings on the Medical Restraint Assessment/Progress Note (Form 617). The assessment shall be done at the beginning of each shift and approximately four (4) hours later for the duration of the order. All assessments shall be documented on the Medical Restraint Nursing Assessment/ Progress Note, Form 617. This form should be filed in chronological order in the Progress Note section of the chart.

(2) All residents in medical restraints must have documentation which indicates that they were observed by an RN/LPN shortly after the beginning of the shift and approximately four (4) hours later. The LPN can observe, gather data, and report.

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

(4) Monthly Progress Note: Prior to a Physician’s Order being rewritten, the registered nurse will assess residents who require medical restraint for chronic conditions (requiring intermittent medical restraints for thirty [30] days or more). For example, a resident who wanders aimlessly and is unable to sit long enough to assure adequate dietary intake may require medical restraint during mealtimes only. This monthly progress note shall include:

(a) assessment by the registered nurse of the continued use of medical restraint;

(b) attempts at lesser restrictive methods, i.e., trial periods without medical restraints;

(c) the resident's physical, mental, psychosocial and functional status;

(d) any condition(s) associated with the use of medical restraint--i.e., has the use of medical restraints been associated with 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, etc.?

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(e) observation(s) and data gathered by the LPN.

(5) Ongoing documentation of the use of medical restraints will continue throughout the duration of the condition.

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

l. 180 Day Review: Each resident placed in extended medical restraints must be reviewed by the medical physician and Recovery Team at least every 180 days. One review will be done either at the time of the annual physical exam or within six (6) months, whichever comes first. This process should cycle to coincide with the annual physical. The review will document the rationale for the extended medical restraint. 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 facilitator. The form will be submitted to the physician for review and signature.

m. Data Input: The Unit Director will assign responsibility for entering all occurrences of medical restraints into the Hospital’s electronic data base. Data for the previous month will be input by the first workday of the month. New medical restraint orders will be entered as they occur.

7. General Information:

a. Medical restraints are physical restraints designed to contain or restrict movement of a resident with the minimum of discomfort and pain, in order to protect self or prevent self-injury.

b. Medical restraints are generally used to prevent a resident with severe physical or mental disorder from harming self and/or preventing exacerbation of an existing medical condition or tissue/organ injury.

c. The use of restraints for the prevention of falls should not be considered a routine part of a falls prevention program.

d. A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a resident for the purpose of conducting routine physical examinations or tests, or to protect the resident from falling out of bed, or to permit the resident to participate in activities without the risk of physical harm. (This does not include a physical escort.)

NOTE: For clarity, definitions and examples of situations which are not considered medical restraint have been separated from those which will be considered medical restraints.

e. The following are examples and will be considered medical restraints:

(1) Restraint devices used as enablers to promote greater functional independence. An example is a used on a resident who may be confined to bed but is able to sit in a chair. The Posey vest is used for support of body parts.

(2) Medical restraint may be used when a resident is required to have complete bed rest due to a life-threatening illness/surgery, but cannot cognitively understand the medical need for complete bed rest.

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(3) Medical restraints may be used to maintain a resident in isolation to prevent the spread of a communicable disease when the resident will not independently maintain isolation.

(4) Medical restraint may be used to assure the resident does not remove feeding tubes, intravenous tubes, oxygen catheters, Levin tubes, tracheotomy tubes, gastrostomy tubes, sutures, casts, splints, etc.

(5) Medical restraints may 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 continuously even when exhausted; or wander aimlessly and disturb other residents; or puts them at risk for other residents to cause bodily injury. A documentation of mental status exam or other standard assessment should be included to support the team's decision that a resident’s cognitive assessment does not indicate good potential for behavioral training;

(b) Residents who are diabetic and take food from other residents’ trays during mealtime;

(c) Residents who wander at mealtime and unable to 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 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.

f. 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. 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, seat belts in a car, van or other vehicle are safety devices. Wheelchairs are safety devices and are NOT medical restraints.

(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) Gerichair with or without a tabletop when used for a resident who requires assistance with ambulation. In these instances, a gerichair can serve as a physical support if its purpose is to prevent the resident from accidentally injuring him/herself.

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8. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated.

New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training All Employees Clerical Dental Dieticians, Laboratory, Special Therapy, X-Ray Techs DirectCare X Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing X Operations & Facilities (Aramark) Physician/ARNP (Prescriber) X Professional Development Psychology X Quality Improvement Recovery Planning X Rehab Services X Resident Advocacy/Risk Mgt. Social Services X Supervisors/Managers Volunteer Services Other:

MARGUERITE J. MORGAN Hospital Administrator

SUMMARY OF REVISED, ADDED OR DELETED MATERIAL

This policy was review and there were no changes made in the content.

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