5122-26-16.1 Mechanical restraint and seclusion.

(A) The purpose of this rule is to state the specific requirements applicable to mechanical restraint and seclusion.

(B) Mechanical restraint and seclusion shall be used only when there exists an immediate risk of danger to the individual or others and no other safe and effective intervention is possible.

(1) To restraint use that is only associated with medical, dental, diagnostic, or surgical procedures and is based on standard practice for the procedure. Such standard practice may or may not be described in procedure or practice descriptions (e.g., the requirements do not apply to medical immobilization in the form of surgical positioning, iv arm boards, radiotherapy procedures, electroconvulsive therapy, etc.);

(2) When a device is used to meet the assessed needs of an individual who requires adaptive support (e.g., postural support, orthopedic appliances) or protective devices (e.g., helmets, tabletop chairs, bed rails, car seats). Such use is always based on the assessed needs of the individual. Periodic reassessment should assure that the restraint continues to meet an identified individual need;

(3) To physical restraint, time-out or comforting of children when its use is consistent with rules 5122-26-16 to 5122-26-16.3 of the Administrative Code; and

(4) To forensic and corrections restrictions used for security purposes, i.e., for custody, detention, and public safety reasons, and when not involved in the provision of health care.

(D) The type of room in which seclusion is employed shall ensure:

(1) Appropriate temperature control, ventilation and lighting;

(2) The absence of unsafe wall or ceiling fixtures and sharp edges;

(3) The presence of an observation window and, if necessary, wall mirror(s) so that all areas of the room are observable by staff from outside of the room; and

(4) That any furniture present is removable or is securely fixed for safety reasons.

(E) Provisions of this rule shall be carried out by qualified staff only.

(1) Training for staff implementing mechanical restraint and seclusion shall include but not be limited to:

(a) Current certification in cpr and first aid;

(b) The identification and utilization of less restrictive alternatives. Training of staff shall focus upon identifying the earliest precipitant of aggression for patients/clients with a known, suspected, or present history of aggressiveness, and on developing treatment strategies to prevent exacerbation or escalation of these behaviors. Patient/client involvement in the identification of precipitants is paramount; and

(F) Orders shall be written only by a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency for implementation of mechanical restraint and seclusion. Orders may be written for a maximum of:

(1) Two hours for adults;

(2) Two hours for children and adolescents age nine to eighteen; or

(3) One hour for children under age nine.

(G) Prn orders, whether individual or as a part of a protocol, are prohibited.

(H) In an emergency:

(1) Mechanical restraint and/or seclusion may be implemented by staff at the direction and in the presence of a registered nurse.

(2) A verbal order from a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency shall be obtained by the registered nurse upon implementation of mechanical restraint or seclusion or within one hour. Such order shall be signed by a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency within twenty four hours.

(I) After the original order for mechanical restraint and/or seclusion expires, the individual shall receive a face-to-face reassessment by the psychiatrist or other physician with specific clinical privileges or authorization granted by the agency, who shall write a new order if mechanical restraint or seclusion is to be continued. However, agency policy and the original order may permit a registered nurse to perform such reassessment and make a decision to continue the original order for an additional:

(1) Two hours for adults up to a maximum of twenty-four hours;

(2) Two hours for children and adolescents age nine to eighteen up to a maximum of twenty-four hours; or

(3) One hour for children under age nine up to a maximum of twenty-four hours.

(J) When mechanical restraint or seclusion is terminated early and the same behavior is still evident, the original order can be reapplied if it is within one hour of the early release and if alternatives remain ineffective. Otherwise, a new order for application must be obtained.

(K) Continuation of orders cannot under any circumstances exceed the maximums stated in paragraphs (I)(1) to (I)(3) of this rule without a face-to-face reassessment by the psychiatrist or other physician with specific clinical privileges or authorization granted by the agency and a new order.

(1) Such assessment shall be documented in the clinical record. It shall address the need for continued mechanical restraint and/or seclusion. It shall include a mental status examination, physical assessment, gross neurological assessment, and an assessment of the individual’s verbal statements, level of behavioral control, and responses to stimuli and treatment interventions, unless contra-indicated for clear treatment reasons which shall be documented in the clinical record.

(L) Upon any implementation of mechanical restraint or seclusion, a registered nurse, psychiatrist, or other physician with specific clinical privileges or authorization granted by the agency shall:

(1) Perform and document in the clinical record an assessment, including the reason(s) for mechanical restraint or seclusion, prior attempts to use less restrictive interventions, review of any contra-indications for mechanical restraint use or seclusion, and review of all current medications;

(2) Assess and document vital signs including temperature, pulse, respiration and blood pressure; and

(3) Explain to the individual the reason for mechanical restraint or seclusion, and the required behaviors of the individual which would indicate sufficient behavioral control so that mechanical restraint or seclusion can be discontinued.

(M) While in mechanical restraint and/or seclusion, persons shall be continuously monitored, i.e., constant visual observation by staff in a manner most conducive to the situation and/or person’s condition. Documentation of the condition of the person shall be made in the clinical record at routine intervals not to exceed fifteen minutes or more often if the person’s condition so warrants. Such documentation shall address attention to needs regarding meals, fluid intake, hygiene, toileting, ambulation and other needs, as necessary, and the appropriate actions taken.

(1) For individuals in mechanical restraint, an assessment shall include health and related safety concerns including body positioning, comfort and circulation.

(N) Upon conclusion of mechanical restraint and/or seclusion interventions, staff shall meet with the individual for the purpose of:

(1) Assisting the individual to develop an understanding of the precipitants which may have evoked the behaviors necessitating the use of the intervention(s);

(2) Assisting the individual to develop appropriate coping mechanisms or alternate behaviors that could be effectively utilized should similar situations/emotions/thoughts present themselves again; and

(3) Developing and documenting a specific plan of intervention(s) for inclusion in the ITP/ISP, with the intent to avert future need for mechanical restraint and/or seclusion.

(O) Staff shall document the interview process outlined in paragraph (N) of this rule in the clinical record.

(P) Clinically appropriate reason(s) for the inability to implement any portion of this rule shall be documented in the clinical record.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M), 5119.01(G), 5119.01(I)

Rule amplifies: RC 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006