(A) The provision of a physically and psychologically safe environment is a basic foundation and requirement for effective mental health treatment. Treatment environments free of coercive interventions and violence promote positive, trusting relationships and facilitate treatment and recovery.
Physical restraint and seclusion are emergency interventions intended to prevent injury. They are not a form of therapy and may actually be traumatizing to a patient. We thus strive continually to reduce and minimize the use of seclusion and restraint. We recognize that these emergency interventions are to be used only by trained and competent staff and as a last resort in order to eliminate dangerous and potentially harmful behaviors and to preserve safety and dignity. All patients should be assessed for any past exposure to these emergency interventions along with possible alternative interventions based on patient preference and experience.
The fundamental goal of inpatient care is to facilitate recovery from serious mental illness, especially from acute exacerbation of illness that may affect judgment, perception and emotion. Quality inpatient care includes a physically and psychologically safe environment for both patients and staff. The policy and preference of the department is for more positive, supportive and less intrusive measures, including counseling, positive relationships, and creating a therapeutic environment that facilitates treatment and recovery.
To reduce incidents that may lead to injuries, staff should employ a multi-modal approach and interdisciplinary, trauma-informed, proactive intervention treatment perspective. ODMH policy MD-19 "Proactive Positive Interventions" describes appropriate early staff intervention to maximize safety; recommended actions when symptoms of aggression erupt; and necessary debriefing, communication and medication reevaluation after an episode of aggression. In the final section, the policy outlines a staged process for the clinician role in the treatment paradigm for safe and quality care, including psychotropic medication specifics.
Best practices include careful early assessment and documentation of a person's history with a particular emphasis on past trauma or abuse. Seclusion and restraint are extremely intrusive measures to control potentially harmful behavior and to preserve safety. At times, restraint is experienced by patients as a recapitulation of past experience(s) of abuse. Special attention must be given to anticipate, and prevent if possible, or minimize restraint in such cases. The experience of seclusion and restraint is stressful for both staff and patients, requiring debriefing and support for these individuals. The purpose of this rule shall be to define and establish uniform procedures governing the safe, humane, and appropriate use of seclusion and restraint consistent with this philosophy, standards of quality treatment and respect for the rights of patients.
(B) The provisions of this rule shall be applicable to all regional psychiatric hospital inpatient settings operated by the department of mental health.
(2) "Clear treatment reasons" means that permitting the patient to participate will present a substantial risk of physical harm to the patient or others or will substantially preclude effective treatment of the patient. If a restriction is imposed for clear treatment reasons, the patient's written treatment plan shall specify the treatment designed to eliminate the restriction at the earliest possible time.
(3) "Direct care personnel" means personnel with special training, competency and experience in assessing and treating persons with mental illness and whose primary responsibility is for such functions.
(4) "Emergency" means an impending or crisis situation which demands immediate action for preservation of life or prevention of serious bodily harm to the person or others as determined by a licensed physician or registered nurse.
(6) "Mechanical supports" means items used for the purpose of achieving proper body alignment, position and balance. Mechanical supports shall not be considered restraints under this rule when used in this manner. Examples include orthopedic-prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or 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.
(7) "Physical restraint" means any method, or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. For purposes of this rule, physical restraint refers to:
(a) "Manual restraint" means physically holding an individual to restrict an individual's ability to move his or her legs, arms, head, or body, freely.
(b) "Physical restraint with devices" means any method of restricting a person's freedom of movement, physical activity, or normal use of his or her body, using an appliance or device manufactured for this purpose.
(c) "Prone restraint" means all items or measures used to limit or control the movement or normal functioning of any portion, or all of an individual's body while the individual is in a face-down position for an extended period of time. Prone restraint includes manual or physical restraint with devices.
(d) "Transitional hold" means a restraint involving a brief physical positioning of an individual face-down for the purpose of quickly and effectively gaining physical control of that individual in order to prevent harm to self and others, or prior to transport to enable the individual to be transported safely.
(8) "PRN order" means a practitioner's written order for a medication, treatment, or procedure which is only carried out when an individual patient manifests a specific clinical condition.
(9) "Quiet time" means a voluntary procedure through which a patient removes him/herself to an unlocked area from a situation which is too stimulating, in an effort to regain self-control.
(10) "Seclusion" means confinement of a patient alone in a room, locked or unlocked, in which that patient is physically prevented from leaving for any period of time.
(11) "Treatment plan" means a written statement of specific, reasonable and measurable goals and objectives for an individual established by the treatment team, in conjunction with the patient, with specific criteria to evaluate progress towards achieving those objectives.
(12) "Treatment team" means a team comprised of the patient, patient's family as defined and authorized by the patient, psychiatrist, or physician so privileged by the facility, registered nurse, social worker, and other appropriate personnel (such as activity therapist, CPST worker, interpreter, reader, dietitian, occupational therapist, pharmacist, psychologist, and others as appropriate) based on patient needs and requests, and standard-setting agency requirements.
(D) It is the policy of the department that seclusion and restraint shall be applied in a safe and humane manner as measures of last resort. The goal of seclusion and restraint use is to assist the patient in regaining self control and maintaining dignity while reducing the risk of injury to patients and staff. The use of seclusion and restraint shall be consistent with nationally recognized standards for quality treatment and applicable laws.
(1) Regional psychiatric hospital (RPH) policies for seclusion or restraint must require that these measures shall:
(a) Only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible. time;
(b) Not employ 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;
(c) Be employed as a last resort when lesser restrictive measures aimed at assisting a patient to control his or her behavior have failed;
(d) Not be used as coercion, discipline, or punishment; for the convenience of staff; or longer than clinically necessary;
(e) Be employed using the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff or others.
(f) Not cause injury to the patient;
(g) Not be used in place of more appropriate treatment interventions;
(h) Be used in a manner that best protects and maintains the dignity and individuality of each patient, and considers:
(iii) Developmental issues;
(v) History of physical or sexual abuse, or other trauma;
(vi) Medical conditions;
(vii) Physical disabilities; and
(viii) If individual is deaf, hard-of-hearing, or whose primary spoken language is other than English.
(i) Be ordered only by physicians;
(j) Be used to allow the greatest possible comfort of the patient; and
(k) Be vigorously supervised and monitored using individual medical record reviews and aggregate data reviews as part of an ongoing and systematic quality improvement program.
(2) Position in restraint. RPH policies and procedures shall ensure that:
(a) The use of prone restraint is prohibited.
(b) A patient shall be placed in a position that allows airway access and does not compromise respiration, regardless of the method of restraint utilized.
(c) The use of a transitional hold shall be subject to all of the following requirements:
(i) Applied only by staff who have current training on the safe use of this procedure, including how to recognize and respond to signs of distress in the patient.
(ii) Applied only in a manner that does not compromise breathing, including, but not limited to the following:
(a)The weight of the staff shall be placed to the side, rather than on top of the patient. No transitional hold technique shall allow staff to straddle, or bear pressure or weight on, the patient's back while applying the restraint, i.e. no downward pressure may be applied.
(b)No soft device, such as a pillow, blanket or other item, shall be placed under the patient's head or upper body; and
(c)No transitional hold technique shall allow placing the patient's or staff's arms under the patient's head, face, or upper body.
(iii) All staff involved in the procedure must constantly observe the patient's respiration, coloring, and other signs of distress, listen for any complaints of breathing problems, and immediately respond to any observed concerns with the intent to ensure that the patient is safe and suffers no harm.
(iv) Transitional hold may be applied only for the reasonable amount of time necessary to safely bring the patient or situation under control and to ensure the safety of the individuals involved; and
(v) After conclusion of the transitional hold, the patient shall be assessed at least every fifteen minutes, for two hours, to assure that the patient is not in need of medical attention. The results of each assessment shall be documented.
(3) RPH restraint and seclusion policies shall incorporate the following:
(a) Restraint shall be applied with concern for good body alignment and comfort of the patient, and recognition of any medical conditions;
(b) Seclusion may be employed only in rooms which contain proper temperature control, ventilation and lighting, a visual panel of safety glass for staff to make observations, a safe and sanitary environment void of wall/ceiling fixtures and sharp edges, electrical outlets; and include a bed, mattress, bed sheets and pillow unless the patient's condition warrants their removal. Removal requires a physician's written order and documentation of rationale for removal, however, a nurse may initiate their removal and then obtain the physician's order within sixty minutes after the removal.
(4) Steel cuffs or other restraining devices may be used by security staff for custody, detention, and public safety reasons and are not considered behavioral restraints. The use of steel cuffs to restrain a patient on a unit is prohibited.
(1) RPHs may distinguish between manual or physical restraint with devices in policy consistent with regulating and accrediting authorities and this rule.
(2) Approved restraints are indicated below and are to be used in accordance with the limitations stated in this rule.
(a) Physical restraints with devices:
(i) Padded leather cuffs, vinyl flexicuffs, waist/wrist cuffs (pads), and two- and four-point belts and cuffs;
(ii) Mittens securely fastened around the wrist with a tie;
(iii) Any item which inhibits bending of the elbow, wrist, or fingers that was devised by clinical staff to prevent patients who engage in chronic self-mutilation from inflicting injury to themselves and cannot be readily removed by the patient. These items must be approved prior to use by the CCO and the team designated to review behavioral therapy at the RPH;
(iv) Helmets only if the helmets are of an approved type and affixed in such a manner that removal or choking cannot be easily accomplished by patients;
(v) Mechanical supports used for restraint rather than support purposes (e.g., soft ties, geri chairs, and tie jackets) shall be considered physical restraint devices under this rule.
(vi) Items used for medical, surgical or dental procedures shall not be considered restraints under this rule.
(b) Manual restraint. A patient may be physically held by staff in either an emergency situation to prevent injury to the patient or others until appropriate physical restraint devices may be applied, or to control for transporting/transferring. Manual restraint is typically applied for only a brief period of time (less than five minutes).
(3) Quiet time shall not be considered restraint or seclusion.
(a) Quiet time may be initiated by either a staff person or the patient;
(b) The use of quiet time may be part of the plan of care and documented in the patient's medical records;
(c) The quiet area/room utilized for quiet time may be the patient's room or a special room or area designated for quiet time;
(d) Special care must be maintained when a suicidal or self-injurious patient is being authorized to use the quiet area/room; and (e) Only one patient is allowed in the quiet area/room at a time.
(4) Personnel designated below shall be the only individuals permitted to implement/employ specific seclusion and restraint techniques cited if they have been trained and are competent to do so:
(a) Direct care and nursing personnel shall be permitted to implement seclusion and restraint only if these employees have successfully completed training programs on minimizing the use of restraint or seclusion and to maximize safety when using seclusion and/or restraint;
(b) RPH security personnel shall implement seclusion and restraint and assist in the use of these interventions when a patient's behavior is beyond the control of nursing or other direct care personnel only if they have successfully completed training programs on minimizing the use of restraint or seclusion and maximizing safety when using seclusion and/or restraint; and
(c) Any employee who has successfully completed training programs on minimizing the use of restraint or seclusion and maximizing safety when using seclusion and/or restraint shall be permitted to assist in the application of restraints.
(1) RPH policies shall
(a) Allow a patient, as part of treatment planning, the opportunity to identify techniques that would help the patient control his or her behavior; and
(b) Consider a patient's advance directive addressing special safety and treatment if seclusion or restraint is warranted.
(a) Any application of seclusion or restraint of a patient shall require a physician's order. Physician orders are obtained beforehand, as much as possible, but in emergent situations, a registered nurse can direct the use of seclusion or restraint (either a physical restraint with devices or a manual restraint) and obtain a physician's order as soon as possible afterward in accordance with paragraph (F)(2)(e) of this rule. The physician must order seclusion and restraint separately. Each order shall be documented and placed in the patient's medical record.
(b) With the exception of orders for the use of mittens and helmets for patient who exhibit self-injurious behavior, each order for seclusion or restraint shall be in force for no longer than one hour for an initial order, or up to two hours for a renewal. A physician shall personally examine the patient and substantiate the need for continuing the use of physical restraint with devices, or seclusion prior to renewing any order.
(c) The CCO or designee must review any episode of seclusion or restraint which exceeds eight hours before another order may be written.
(d) Orders for restraint devices to prohibit self injury including mittens and helmets shall not exceed four hours, and require a face-to-face evaluation by a physician for renewal in accordance with paragraph (F)(6) of this paragraph.
(e) In situations where, after a series of less restrictive interventions have failed and a seclusion or restraint is needed immediately to control the emergency situation, a patient may be restrained or secluded at the direction of a registered nurse without a written physician's order, if the following requirements are met:
(i) A physician shall be contacted by a registered nurse as soon as possible to obtain a telephone order, but no longer than thirty minutes after the initiation of restraint or seclusion;
(ii) The registered nurse shall explain to the patient the reason for seclusion or restraint and the behaviors of the patient which would indicate sufficient self-control to discontinue the measure;
(iii) The registered nurse shall document the physician's telephone order in the patient's medical record; and
(iv) The physician shall personally examine the patient and document in the chart within one hour after giving/receiving a telephone order to:
(a)Substantiate the need for such a measure, including the clinical indications. Documentation should show that the physician considered both the benefits and risks of these measures;
(b)Perform the medical assessment noted in paragraph (F)(3) of this rule; and
(c)Countersign, date and time the telephone order.
(v) When a nurse initiates seclusion or restraint without a physician's order, and the physician, upon examination, does not substantiate the need for such a measure, the seclusion or restraint shall be terminated immediately.
(a)The results of the examination and rationale for not ordering seclusion or restraint shall be documented by the physician.
(b)The CCO or designee shall review all of the documentation related to the seclusion or restraint.
(f) Standing or PRN orders for seclusion or restraint shall not be used.
The physician shall personally examine the patient who has been secluded or restrained in conjunction with writing orders for these interventions. The patient shall be given an explanation of the reason for the restraint or seclusion, and the behaviors of the patient which would indicate sufficient behavioral control to discontinue the intervention. The examination shall include the following unless clinically contraindicated and documented in the patient's record:
(a) An assessment of any physical problems or an unstable medical status that might contraindicate the use of seclusion or restraint. If there are none, the evaluator shall document in the patient's medical record that there are no known contraindications to this seclusion or restraint procedure;
(b) Vital signs including temperature, pulse, respiration, and blood pressure, or documentation if not done, and why;
(c) A review of current medications if the evaluation is conducted by a physician;
(d) Documentation to substantiate the clinical indication for seclusion or restraint use, and that the evaluator considered both the benefits and risks of these measures; and
(e) If the one hour face-to-face evaluation is conducted by a physician other than the attending physician, the attending physician or other licensed independent practitioner responsible for the care of the patient must be consulted as soon as possible.
(4) Rationale for the release from seclusion or restraint shall be documented by the registered nurse or licensed practical nurse in the patient's medical record.
(5) The treating physician shall be contacted as soon as possible if the restraint or seclusion was ordered by another physician.
(6) Patient care and documentation standards.
(a) All prior interventions used before seclusion or restraint shall be documented in the patient's medical record.
(b) To ensure proper safety, body comfort, and circulation of a patient placed in restraints, checks of the patient's condition shall be made by direct care personnel.
(i) Patients placed in restraints or seclusion shall be continuously monitored. Observations of the condition of the patient shall be made and documented in the patient's medical record at least every fifteen minutes or more often if the patient's condition so warrants.
(ii) Appropriate assessments of a patient in restraint or seclusion shall be conducted every fifteen minutes by trained and competent staff, and documented in the patient's medical record. The fifteen minute assessments shall include, as applicable: signs of any injury; nutrition/hydration; circulation and range of motion in the extremities; vital signs; hygiene and elimination; physical and psychological status and comfort; and readiness for discontinuation of restraint or seclusion.
(iii) When a patient is removed from physical restraint with devices, nursing staff shall continue to monitor the progress of the patient and make at least one entry, including vital signs, within two hours in the patient's medical record concerning the patient's status. More frequent monitoring may be necessary if warranted by the patient's condition.
(c) All patients placed in restraint or seclusion shall be visited by a registered nurse or licensed practical nurse no less than every hour to assess the patient. These visits shall be documented in the patient's medical record. This contact may be modified by a physician's order if the patient's need for reduced stimulus outweighs the need for continued medical assessment.
(d) A patient placed in restraint or seclusion shall be provided the opportunity for motion and exercise for at least ten minutes during each two hour period in which these devices are employed. This shall be documented in the patient's medical record.
(e) The patient's medical record shall include documentation of fluids being offered and monitoring for fluid intake and output. Monitoring may be modified by a physician's order if the patient's condition warrants reduced monitoring. The physician's order shall include rationale for the reduction in monitoring of fluid intake and output.
(f) The rationale for each episode of seclusion or restraint shall be clearly documented in the patient's medical record by the physician who examined the patient.
(g) The physician shall specify criteria for discontinuation of seclusion and/or restraint.
(h) With the patient's consent, the patient's family is notified of the initiation of restraint or seclusion.
(7) Conduct debriefings after an incident. (See ODMH policy MD-19 "Proactive Positive Intervention Treatment and Safety").
(a) The goals of debriefing are to:
(1) minimize the negative effects of the incident on all involved individuals; and
(2) identify alternatives strategies to prevent or minimize future occurrences.
(b) Each patient shall be given the opportunity to debrief each episode of seclusion or restraint, unless specifically contraindicated in the treatment plan for clear treatment reasons. As part of the debriefing, the patient shall be given the opportunity to identify techniques that would assist the patient to control his or her behavior. In addition, patient debriefing provides an opportunity to minimize trauma and reestablish the therapeutic staff-patient relationship. Families may also participate in the debriefings at the patient's request.
(c) Each RPH shall develop procedures to debrief staff after an episode of restraint. Conduct a staff debriefing when a physical intervention occurs to:
(i) Assess for any injury;
(ii) Plan next steps for the patient's care and protection for the remainder of the shift;
(iii) Determine how management of the situation could have been handled differently;
(iv) Provide information to patient's treatment team to assist in treatment plan revisions;
(v) The following are examples of questions that may be included in a staff debriefing:
(a)Were there alternative actions that could have been taken to prevent the incident?
(b)Could some intervention earlier in the prodrome have prevented the outcome?
(c)In the case of restraint, could seclusion have been an alternative?
(d)Would it be possible to achieve a better outcome if an assist team were called?
(e)Are we medicating optimally? Is the patient adherent? How do we respond to possible non-adherence?
(f)What environmental changes might minimize the risk of further dangerous behaviors (e.g., room changes, roommate changes, ambient noise, light, or congestion on the unit, access to exits, response to visitors, etc.)?
(8) Monitoring and quality improvement requirements
(a) Each unit shall be responsible for preparing a daily log indicating name of patient, patient number, living unit, time of day in, time of day out, for each episode of seclusion or restraint.
(b) The regional psychiatric hospital CCO or his/her designee and the director of nursing/nurse executive and/or his or her designee shall review, daily, all uses of seclusion or restraint.
(c) The quality improvement review of restraint and seclusion shall include, at a minimum, the following:
(i) A review of the aggregate monthly totals of the use of restraint or seclusion by type, ward, time of day, and other data required in paragraph (F) of this rule;
(ii) The review of any major incidents that resulted in the use of seclusion or restraint;
(iii) Within one business day, the treatment team shall conduct a review of any patient who required any seclusion or restraint. During this review the current treatment plan shall be assessed and revised as needed to contain specific elements that are aimed at reducing the use of seclusion or restraint. All prior interventions shall be reviewed. If successive treatment plan revisions are not successful in reducing the use of seclusion or physical restraint with devices in a clinically reasonable amount of time, consultation from outside the treatment team must be obtained. The department or regional psychiatric hospital behavior therapy committee, the CCO, other treatment teams, private consultants etc. may be sources utilized to conduct a consultation; and
(iv) The findings from the activities under paragraph (F) of this rule shall be reviewed monthly. This review shall identify any trends, increases, and problems. The need for additional training, consultations, or corrective action will be noted in the minutes of that review and forwarded to the CCO for possible action.
(v) The data collected in paragraph (F) of this rule and other related quality improvement review information shall be available to central office.
(d) Each patient, unless specifically contraindicated in the treatment plan for clear treatment reasons, shall be given the opportunity to debrief each episode of seclusion or restraint. As part of the debriefing, the patient shall be given the opportunity to identify techniques that would assist the patient to control his or her behavior. This shall be documented in the patient's medical record.
(e) Each regional psychiatric hospital shall develop procedures to debrief staff after an episode of restraint.
(G) Orientation and training
(1) Each chief executive officer shall be responsible for ensuring that orientation and training programs regarding the use of seclusion and restraint are provided. These programs shall be provided and conducted by appropriate personnel.
(2) Training shall emphasize the use of non-physical crisis intervention, behavioral and other treatment strategies to prevent exacerbation of aggression, and other techniques that will reduce the use of restraints. Special attention shall be placed on the humane use of any restraint technique.
(a) All personnel shall have appropriate training during employee orientation.
(b) All new and existing direct care personnel and regional psychiatric hospital security personnel shall receive training in behavioral and other techniques to reduce the use of seclusion or restraint, and the proper use of physical restraint, manual restraint, and seclusion. This training will be conducted at least annually or more often if indicated by quality improvement reviews.
(c) Upon successful completion of each orientation or training program, a record of this training shall be documented and maintained in each employee's personnel folder.
The chief executive officer of each RPH shall be responsible for implementation of this rule.
Cite as Ohio Admin. Code 5122-2-17
Promulgated Under: 111.15
Statutory Authority: 5119.01, 5119.07, 5122-27, 5122-29
Rule Amplifies: 5119.01, 5119.07, 5119.82, 5122-27, 5122-29
Prior Effective Dates: 4-24-1978, 7-1-1980, 1-11-1991, 6-1-2000, 7-15-2002