LABETTE HEALTH POLICY AND PROCEDURE SUBJECT: RESTRAINT REFERENCE:A/N/SWING BED/ER APPROVED BY: Restraint Committee PAGE 1 OF 10 EFFECTIVE: SEPT/97 REVISED: FEB/JULY99 MAR/01, JAN/02, OCT/03, DEC/03 AUG/05/MAY/07/JULY/08, APR/09, OCT/09, APRIL/12 TITLE: RESTRAINT

DEFINITIONS: A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or 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 and is not a standard treatment or dosage for the patient’s condition.

Patients Who May Require Restraint 1. Non-violent or non-self destructive patients (Medical): patients who require restraints to prevent removal of tubes, lines, dressings, or to support medical healing or well-being. 2. Violent or self-destructive patients (Behavior): patients who display severely aggressive or destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others. This category includes patients for which a Dr. Strong might be called.

POLICY: 1. It is the intent of Labette Health to be Restraint free. 2. All patients have the right to be free from restraints or seclusion of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Labette Health does not use seclusion as a form of restraint. 4. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury. 5. The application of the least restrictive physical restraint necessary will be limited to clinically appropriate and clinically justifiable situations when documented alternatives are unsuccessful. 6. Clinical staff not trained in restraints will contact nursing staff trained in restraints when requiring assistance removing or reapplying restraints. 7. The type of restraint employed shall be consistent with the behavior demonstrated by the patient. The type of restraint selected will be the least restrictive of the appropriate choices available and is to be applied in such a manner that there is due regard for the comfort, privacy, and dignity of the individual. Every patient has the right to be treated with dignity and respect. 8. The condition of the restrained patient must be continually assessed, monitored, reevaluated, and documented. 9. The patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patients medical symptoms. 10. The patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 11. Restraints may be used in response to emergent, dangerous behavior, addictive disorders, as an adjunct to planned care. 2 12. Restraints may be used to protect the patient’s safety and the safety of others. Because restraints may be necessary for certain patients, our health care organizations and providers need to be aware of the associated risks of both use and non-use. Restraints may be necessary in order to prevent significant harm to the patient 13. Restraints are to be applied as humanely as possible. Caregivers will be sensitive to the effects of restraint on the patient's self esteem, feelings of independence and pride. 14. Restraints are never to be used as punitive measure or for the convenience of caregivers. Restraints are not to be used in a manner that causes undue harm, physical discomfort or pain to the patient. 15. Patient and family will be involved in the decision to use restraints to fullest extent possible. 16. Patient and family will be educated about safety measures and care while restraints are in place. 17. The plan of care should be modified to reflect the use of Restraints.

PHYSICIAN ORDER A physician’s order is required for the application of restraints. NOTE: PRN or routine (standing) orders for use of restraints will not be accepted. 1. Initial restraint orders may be given to the RN in print, verbal, or telephone format. The preprint restraint order sheet or an electronic order will be completed and placed on the patients chart. 2. All restraint orders (initial and renewal ) must include the following: a. date and time b. time limit c. type of restraint d. list of behavior necessitating use of restraint e. physician’ signature 3. To ensure continuity of care, if a physician other than the patient’s attending physician orders restraints, the attending physician will be notified as soon as possible about the use of restraints on his/her pateint. 4. Restraint order renewal: Prior to implementing a renewal order for restraint, the physician must see the pateint and evaluate the need for continued restraint by completing a face-to face evaluation within time frame of the order.

Specific Requirements for Use of Restraints on Non-Violent or Non-Self Destructive Pateints (Medical) A. A physician’s order will be obtained prior to the application of restraints. B. The original order must be renewed within each 24 hours period/calendar day. If restraints are removed for reasons other that nursing care, a new order must be obtained prior to re-application of restraints. C. Restraints will be discontinued at the earliest possible time, regardless of the time specified in the physician’s orders. D. Patients in restraints will be regularly monitored/ assessed. The Restraint Flow chart will contain every 2 hour documentation by the RN.

3 Specific Requirements for Use of Restraint on Violent or Self-Destructive Pateints (Behavioral) In some situations the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. In these emergency application situations: A. The order must be obtained either during the emergency application of the restraint or immediately (without time interval) after the restraint has been applied. B. The RN or licensed staff will document the assessment findings and justification for emergency restraint application in the patients record. C. A physician will be asked to conduct a face to face evaluation within one hour after restraint application to evaluate the pateints immediate situation, response to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints. If a physician other than the attending physician conducts the face to face evaluation, the attending will be notified by phone of the evaluation.

Physician’s orders may only be renewed in accordance with the following limits for up to a total of 24 hours: (Behavior) 3 hours adult(18 years old and older) 2 hours children ages 9-17 1 hour children under 9 D. Patients in restraints will be regularly monitored and assessed. The Restraint Flow sheet will be completed every 2hours by the RN. E. Restraints will be discontinued at the earliest possible time, regardless of the time specified in the physician’s order.

PROCEDURE: Assessment and Clinical Justification 1. Restraints will only be utilized in situations when less restrictive measures have been attempted and are unsuccessful and documented. Such as: a. 1:1 talk b. PRN Medication c. Attempted reorientation d. Placed near nursing station e. Chair time f. Team support g. Pain level assessed and attended to h. Quiet time i. Relaxation Activity j. Bed alarm k. Environmental noise controlled l. Redirect patient's focus m. Attempted toileting n. Requested family to stay with patient o. Food/fluids offered p. Side Rails up X’s 3 2. Restraint use is based on a thorough assessment of the patient and is based on individual need and clinical justification for use. Such as: a. Interference with medical devices, tubes, dressings, or other essential treatment modalities. b. Altered Mental Status (Document, identify specific behavior). c. Marked agitation d. Altered level of consciousness 4 e. Neurological impairment due to anesthesia, longer than 30 min. post- anesthesia care. f. Unable to comprehend the seriousness of condition or the need for treatment. g. High risk of injury to self or high risk of injury to others. 3. Explain to the patient and/or family the plan and rationale for using restraints and the condition/behavior required for release from restraints. a. Document patient/family articulation of understanding, b. If patient/family unable to articulate understanding document reason.

MONITORING, REASSESSMENT ,DOCUMENTATION 1. The patient is to be monitored at least every 15 minutes via a visual observation by a member of the patient care team. 2. The visual observation is to include a visual circulation check to any restrained extremity, proper positioning of the patient and restraints, and that the patient has not harmed him or herself. 3. The RN assesses the patient at intervals not greater than 2 hours. The assessment includes the following: a. Neurologic, level of consciousness, orientation and emotional status to determine if the clinical justification for restraint continues or if there is a potential for reduction or removal of restraints. b. Proper application of restraint. c. Circulation, joint mobility and sensation of affected limb(s) d. Skin integrity under the restraint. Physical needs, ROM/activity, elimination, nutrition and hydration. 4. Assessment should be performed more frequently as warranted by the condition of the patient and type of restraint. 5. Restrains will be released at least every 2 hours for 10 minutes. 6. The use of restraints will be terminated as soon as criteria for release of restraints have been met.

DOCUMENTATION 1. Assessment and clinical justification for the use of restraints. 2. Behavior that warranted restraint use 3. The less restrictive measures that have been attempted and the patient response to the measures 4. The type of restraint. 5. The time restraints were applied safely and properly and discontinued. 6. Every 2 hr. documentation of visual observation of the patient. 7. The reassessment completed at least every 2 hours or more often as warranted by the patient's condition. 8. Release of restraint every 2 hours for 10 minutes. 9. The provision of ROM, nutrition, hydration and attention to elimination, skin integrity under the restraint need to be documented every 2 hours. 10. Patient and family education 11. Criteria for release of restraint. 12. Any patient in restraints will have risk for injury addressed on Problem List/Care Plan.

5 GUIDELINES FOR APPLICATION 1. Apply device according to manufacturer instructions. . 2. Apply restraint that is appropriately sized for body part being restrained. 3. Restraints are contraindicated over wounds or intravenous catheters because thy can cause skin irritations and restrict blood flow. Do not apply a limb restraint above an IV site, as this may occlude the infusion or cause infiltration. a. Secure restraints to the bed frame ONLY. b. The length of the strap must be adjusted to the maximum length possible. 4. Place the call light within reach.

STAFF EDUCATION, TRAINING, AND COMPENTENCY Restraint education and training will be developed and provided by an RN who is competent to train staff in applying and care of patients in restraints. The patient hs the right to have safe implementation of restraints by trained staff. 1. All nursing direct care staff will complete restraint education and training beginning during the orientation phase and continuing on an annual basis. 2. Education will include: a. Behaviors, assessments, and clinical justification that may require the use of restraints. b. The use of less restrictive measures have been attempted and documented as being unsuccessful. c. Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical and/or behavior condition. d. Safe application and use of restraints, including training to recognized and respond to signs of distress and emergency procedures. e. Behaviors that indicate that restraint is no longer needed. f. Nursing care needed and documentation. 3. Staff will demonstrate competency in the application, removal, monitoring, assessment, and care of patients in restraints. 4. Documentation of staff training will be maintained in personnel files. 5. Ordering physicians will be educated on policy for restraint use.

CHEMICAL RESTRAINTS

Chemical Restraint is a drug or medication when it is used as a restriction to manage the patient’s freedom or movement and is not a standard treatment or dosage for the patient’s condition.

Instruct patient/family on the following upon initiation of chemical restraint: 1. Potential side effects from these types of medications. 2. The increased potential for falling. 3. The need to call for assistance when getting out of bed and ambulating.

Continued Need: Discuss restraint condition of patient with appropriate physician during daily rounds. Consider alternate strategies for behavior control. Monitoring 1. Monitor sensorium/alertness/orientation/gait, balance control associated with ambulating and self care activities every shift. 2. Determine Fall Risk every shift and follow the appropriate Fall Risk Policy and Procedure and appropriate Fall Risk Documentation. 6 3. Assist patient with ambulation, self-care and toileting as indicated. 4. Use side rails X’s 3 and ensure that call light is within reach. 5. Instruct and re-instruct patient on calling for help prior to getting out of bed. 6. Monitor for signs of specific drugs side effects including constipation, dehydration and others.

EXCLUSIONS 1. Standard practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related procedural process (for example, surgical positioning, intravenous arm boards, radiotherapy procedures, protection of surgical and treatment sites in pediatric patients) 2. A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or methods that involve the physical holding of patient for the purpose of conducting routine tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm. 3. Adaptive support in response to assessed patient need (for example, postural support, orthopedic appliances, helmets.

RESTRAINT LOG AND CMS REPORTING REQUIEMENTS

Each unit will document restraint activity on a restraint log. The log will be maintained by the nursing units and monitored by the charge nurses, admission nurse, staff nurses, and the Nurse Director of the unit.

The following cases will be reposted to CMS: 1. Each death that occurs while a patient is in restraint. 2. Each death that occurs within 24 hours after the pateint has been removed from restraint. 3. Each death that occurs within one week after restrain where it is reasonable to assume that the use of restraint contributed directly or indirectly to the patient's death.

In the event of a death of a patient who meets the above CMS criteria, staff will notify the Director of Risk Management, Nurse Director, or Nursing Supervisor, and fill out the Risk Management Death of a patient in restraint notification form. (attached). CMS must be called at the number below, no later than the close of the next business day. Followed by the required fax report. (also attached)

Staff must document in the patients medical record the date and time the death was reported to CMS. Report will be made to: CMS Region 7,Richard Bolling Federal Building, Room 235, 603 East 12th Street, Kansas City, MO 64106. Phone 816-426-2011:, Fax: 816-235-7003.

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Risk Management Patient Death Notification Form Of Patients in Restraints

Please check all that apply: _____ Patient died while restrained _____ Patient died within 24 hours after the patient has been removed from restraint. ___ Patient death occurred within one week after restraint where it is reasonable to assume that the use of restraint contributed directly or indirectly to the patient's death.

Date of this report ______

Patient Name / Room Number ______

Patient Acct. Number______

Date of Patient Death ______

Restraint Type- _____Medical ______Behavioral

Nurse ______

*****Reminder: Document date and time of CMS notification in pt. record as required.

CMS Region 7,Richard Bolling Federal Building, Room 235, 603 East 12th Street, Kansas City, MO 64106. Phone 816-426-5233:, Fax: 816-426-6769.

* Upon completion of this document, please forward immediately to the Quality / Risk Management Office. ** This document does NOT become a part of the patient medical record.

CC: Department Director

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1902 S US Hwy 59 Parsons, KS 67357 Fax number : 620-820- 5399 Phone (620) 820-5385

FAX

To: CMS From:______

Fax: ____816-235-7033______Pages: Including cover sheet______

Phone: __816-426-2011______Date: ______

Re:______cc:______

▫ Urgent ▫ For Review ▫ Please Comment ▫ Please Reply ▫ Please Recycle

Comments: Restraint Worksheet

Confidentiality Notice: This fax message and any attachments are for the sole use of the intended recipient (s) and may contain proprietary, confidential, trade secret or privileged information. Any unauthorized review, use, disclosure, or distribution is prohibited and may be a violation of law. If you are not the intended recipient or a person responsible for delivering this message to an intended recipient, please contact the sender by phone and destroy all copies of the original message immediately.

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HOSPITAL RESTRAINT/SECLUSION DEATH REPORT WORKSHEET Revised July 2009

The following table includes only the mandatory fields required.

Date reported by CMS Regional Office A. Provider information Hospital Name CMS Certification Number Name of Person Filing the report Filer’s Phone Number B. Patient Information Patient Name Date of Birth Date of Admission Date of Death Cause of Death Did the patient die: (place an “X” in the Appropriate box to the right below) While in Restraints/Seclusion Within 24 hours of removal of restraint, seclusion, or both. Within 1 week where restraint, seclusion or both contributed to the patient’s death Type Used: (place and “X” in the appropriate box to the right of each applicable). Physical Restraint Seclusion Drug Used as Restraint Was a 2-point soft wrist restraint used alone, without seclusion or chemical restraint or any other type of physical restraint? Yes X If “yes”, check “02” below and stop. No further information is required. No If “no”, complete the entire form (i.e., all fields). If physical restraint(s), type: (check all applicable) 01 Side Rails 02 2-point soft wrist NOTE: If 2-point soft wrist restraint was used alone 03 2-point hard wrist (without seclusion, chemical restraint, or any other 04 4-point soft restraints type of physical restraint), no further information is 05 4-point hard restraints required. 06 Forced medication holds 07 Therapeutic hold(s) 08 Take-down(s) 09 Other physical hold(s) 10 Enclosed bed 11 Vest restraint 12 Elbow immobilizer(s) 13 Law enforcement restraint(s)

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NOTE: The information on this page is not required if 2-point wrist restraint was used alone, without seclusion or chemical restraint or any other type of physical restraint.

For Drug Used as Restraint: C. Hospital-Reported Restraint/Seclusion Information Total length of time in Restraint/Seclusion Was restraint/Seclusion used to manage violent or self-destructive behavior? Yes No If “yes”: Reason(s) for restraint/seclusion use Was 1-hour face-to-face evaluation documented Yes No Date/Time of last face-to-face evaluation Was the order renewed at appropriate intervals based on the patient’s age?

NOTE: Orders may be renewed for up to a total of 24 hours, at the following intervals:  18 years – every 4 hours  9-17 years – every 2 hours  < 9 years – every hour

Yes No If simultaneous restraint and seclusion was ordered, describe continuous monitoring methods (s) D. RO Actions Was survey authorized: Yes No If yes, date RO contact P&A