Primary regulation

42 CFR 482.13 and 42 CFR 482.60

Who can order it

“The use of a restraint or seclusion must be... in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order seclusion or restraint.” 42 CFR 482.13(f)(3)(ii). “The treating physician must be consulted as soon as possible, if the restraint or seclusion is not ordered by the patient's treating physician.” 42 CFR 482.13(f)(3)(ii)(B).

When does an MD have to cosign

Always. “The use of a restraint or seclusion must be... in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order seclusion or restraint.” 42 CFR 482.13(f)(3)(ii).

Is the presence of an MD required to apply

No, but “a physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention.” 42 CFR 482.13(f)(3)(ii)(C). Superseded by state law if more restrictive. 

Duration of each order

“Each written order for a physical restraint or seclusion is limited to 4 hours for adults; 2 hours for children and adolescents ages 9 to 17; or 1 hour for patients under 9. The original order may only be renewed... for up to a total of 24 hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must see and assess the patient before issuing a new order.” 42 CFR 482.13(f)(3)(ii)(D). Superseded by state law if more restrictive.

How often must they check on patients

The condition of the patient in a restraint or seclusion must be continually assessed, monitored, and reevaluated. 42 CFR 482.13(f)(5).

 When in restraint and seclusion, must be continually monitored face-to-face or by staff using both video & audio equipment and in close proximity.  42 CFR 482.13(f)(4).

Staff training required

“All staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint… and alternative methods for handling behavior, symptoms, and situation that traditionally have been treated through the use of restraints or seclusion.” 42 CFR 482.13(f)(6).

Restraint

Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that s/he cannot easily remove that restricts freedom of movement or normal access to one’s body.

42 CFR 482.13(f)(1).

Chemical Restraints

“A drug used as a restraint is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.” 42 CFR 482.13(f)(1).

Seclusion

“Seclusion is the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.” 42 CFR 482.13(f)(1).

“A restraint and seclusion may not be used simultaneously unless the patient is… continually monitored face-to-face by an assigned staff member; or continually monitored by staff using both video and audio equipment. This monitoring must be in close proximity to the patient.” 42 CFR 482.13(f)(3)(ii).

Postural Supports

Documentation

“The hospital must report to CMS[1] any death that occurs while a patient is restrained or in seclusion, or where it is reasonable to assume that a patient's death is a result of restraint or seclusion.” 42 CFR 483.13(f)(7).

Alternatives required

“Seclusion and restraint can only be used in emergency situations if needed to ensure the patient's physical safety and less restrictive interventions have been determined to be ineffective [to protect the patient or others from harm].” 42 CFR 482.13(f)(2) & (3)(i).

Primary regulation

22 CCR 70577(j)

Who can order it

“[O]nly on the... order of the physician or clinical psychologist.  In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).

When does an MD have to cosign

Always.  “If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 70577(j)(2).

Is the presence of an MD required to apply

No. “In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).

Duration of each order

How often must they check on patients

“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 70577(j)(3).

Staff training required

“Psychiatric unit staff shall be involved in orientation and in-service training of hospital employees. Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.” 22 CCR 70577(l) and (m).

Restraint

“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion or mechanical devices.” 22 CCR 70059.

Chemical Restraints

Seclusion

Same as restraint.

Postural Supports

Documentation

“Record of type of restraint including time of application and removal shall be in the patient's medical record.” 22 CCR 70577(j)(5). “If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 70577(j)(2).

Alternatives required

“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 70577(j)(1).

Primary regulation

Hospital Accreditation Standards (HAS) (2005) PC.12[2]

Who can order it

“[O]rdered by a licensed independent practitioner (LIP) (“Any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges"). HAS Glossary.

Qualified, trained staff members (authorized by the hospital or permitted by state law)… may initiate.  Must obtain order from LIP as soon as possible, no longer than one hour.  PC.12.70.

When does an MD have to cosign

Is the presence of an MD required to apply

No.

LIP evaluates in-person within:

-        4 hours of initiation for adults;

-        2 hours of initiation for child 17 and under.

PC.12.90.

Thereafter, LIP conducts in-person reevaluation:

-        every 8 hours for adults;

-        every 4 hours for children under 17 years.

PC.12.110.

LIP evaluates in-person a patient released from restraint or seclusion within 24 hours of the initiation of the restraint or seclusion.  PC.12.90.

Duration of each order

Orders for restraint or seclusion are limited to:

-        every 4 hours for adults;

-        every 2 hours for children 9 -17 years;

-        every 1 hour for children under 9 year.

PC.12.100.

Extended duration restraint/seclusion

Clinical leaders notified of restraint/seclusion:

-        extending beyond 12 hours;

-        occurring two or more times within 12 hours;

-        thereafter, every 24 hours.

PC.12.120.

How often must they check on patients

-        Continuous in-person observation;

-        After first hour of seclusion only, may continuously monitor by video and audio equipment;

-        Second staff member required to observe during physical holds.

PC.12.140.

Patient assessed and assisted every 15 minutes. PC.12.130.

Staff training required

Staff is trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely.  PC.12.30.

Restraint

Any method (chemical or physical) of restricting a patient’s freedom of movement, including seclusion, physical activity, or normal access to his/her body that:

-        is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his/her legal representative has consented;

-        is not indicated to treat the patient’s medical condition or symptoms; or

-        does not promote the patient’s independent functioning.

HAS glossary.

Chemical Restraints

“The inappropriate use of a sedating psychotropic drug to manage or control behavior.” HAS glossary.

Seclusion

Included in definition of restraint.

Postural Supports

Restraint standards in acute medical and surgical (non-psychiatric) care are covered under separate requirements. PC. 11.10 – 11.100.

Documentation

Medical records document that the use of restraint or seclusion is consistent with hospital policy.  Includes specific requirements.   PC.12.170.

Alternatives required

Limited to emergencies in which there is an imminent risk of a patient physically harming him/herself, staff, or others, and nonphysical interventions would not be effective.  PC.12.60.

Primary regulation

22 CCR 71545

Who can order it

“[O]nly on the... order of the physician or clinical psychologist.  In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 71545(b).

When does an MD have to cosign

“If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 71545(b).

Is the presence of an MD required to apply

No.

Duration of each order

How often must they check on patients

“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 71545(c).

Staff training required

Restraint

“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion, medication or mechanical devices.” 22 CCR 71055.

Chemical Restraints

Same as restraint.

Seclusion

Same as restraint.

Postural Supports

Documentation

“This order shall include the reason for restraint and the type of restraint being used…. If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 71545(b).

Alternatives required

“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 71545(a).