(A) The provision of a physically and
psychologically safe environment is a basic requirement for effective mental
health treatment. Treatment environments free of coercive interventions and
violence promote positive, trusting relationships and facilitate treatment and
Seclusion and physical restraint are emergency
interventions intended to prevent patient and staff injury. They are not a form
of therapy and may be traumatizing to a patient. We strive continually to
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, emotion, and
behavior. Quality inpatient care includes a physically and psychologically safe
environment for both patients and staff. The preference of the department is
for the use of positive, supportive and less intrusive measures to engage
patients in treatment, including the use of counseling, positive relationships,
and a therapeutic environment that facilitates treatment and recovery.
To reduce incidents that may lead to injuries,
staff should employ a multi-modal approach and an interdisciplinary,
trauma-informed, proactive intervention perspective.
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 and addiction services (OhioMHAS).
(C) The following definitions apply to
this rule in addition to or in place of those appearing in rule 5122-1-01 of
the Administrative Code:
(1) "Chief clinical
officer (CCO)" means the medical director of a regional psychiatric
hospital (RPH) as defined in division (K) of section 5122.01 of the Revised
(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.
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, licensed practitioner, or
registered nurse (RN).
services security personnel" means special police as defined in section
5119.08 of the Revised Code and security officers of the regional psychiatric
practitioner" means an individual who is responsible for the care of the
patient and authorized to order restraint or seclusion by hospital policy in
accordance with state law and specifically refers to advanced practice nurses
(APN) and physician assistants.
(7) "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
(8) "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 persons freedom of movement, physical activity, or
normal use of his or her body, using an appliance or device manufactured for
(c) "Prone restraint" means measures used to limit or
control the movement 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, and enable the individual to be transported
(9) "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
(10) "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
(11) "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
(12) "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
(13) "Treatment team" means a
team comprised of the patient, patient's family as defined and authorized
by the patient, psychiatrist, licensed practitioner, or physician so privileged
by the facility, RN, social worker, and other appropriate personnel (such as
activity therapist, CPST worker, interpreter, dietitian, occupational
therapist, pharmacist, psychologist, counselors, and others as appropriate)
based on patient needs and requests, and standard-setting agency
(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) 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
(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
(f) Not cause injury to the patient;
(g) Not be used in place of more appropriate treatment
(h) Be used in a manner that best protects and maintains the
dignity and individuality of each patient, and considers:
(v) History of physical
or sexual abuse, or other trauma;
(viii) If individual is
deaf, hard-of-hearing, or has a primary spoken language is other than
(i) Be ordered only by physicians or a licensed
(j) Be used in a manner to provide for 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
(c) The use of a transitional hold shall be:
(i) Applied only in a manner that does not compromise
(ii) Only for the brief
amount of time necessary to bring the patient under control and ensure safe
(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
(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 with no
wall/ceiling fixtures and sharp edges or electrical outlets. The room must
include a bed, mattress, bed sheets, and pillow unless the patient's
condition warrants their removal. Removal of these items requires a
physician's or licensed practitioner's written order and
documentation of rationale for removal, however, a nurse may initiate their
removal and then obtain the physician's or licensed practitioner's
order within sixty minutes after the removal.
(4) Steel cuffs or other
restraining devices used by security staff for custody, detention, and public
safety reasons 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
(ii) Mittens securely
fastened around the wrist with a tie;
(iii) Helmets only if the helmets are of an approved type and
affixed in such a manner that removal or choking cannot be easily accomplished
(iv) 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.
(v) Items used for medical, surgical or dental procedures
shall not be considered restraints under this rule.
(b) Manual restraint. May be utilized 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. Manual
restraint is typically applied for only a brief time period (less than ten
(3) Quiet time shall not
be considered restraint or seclusion.
(4) Personnel designated
below shall be the only individuals permitted to implement seclusion and
restraint 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;
(b) RPH security personnel shall assist in the use of these
interventions only when requested to do so by direct care or nursing personnel;
(c) Other employees who have successfully completed
training programs on the use of restraint or seclusion shall be permitted to
assist in their application.
(1) RPH policies
(a) Allow a patient, as part of treatment planning, the
opportunity to identify techniques that would help control his or her behavior;
(b) Consider a patient's advance directive addressing
special safety and treatment if seclusion or restraint is
(a) Any application of seclusion or restraint of a patient shall
require an order by a physician or another licensed practitioner. This order is
obtained beforehand, as much as possible, but in emergent situations, a (RN)
can direct the use of seclusion or restraint (either a physical restraint with
devices or a manual restraint) and obtain the order as soon as possible
afterward in accordance with paragraph (F)(2)(e) of this rule. The order must
specify the use of seclusion and restraint separately. Each order shall be
documented to include parameters for discontinuation of the intervention
(seclusion and/or restraint) and placed in the patient's medical
(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 four hours for a renewal. A physician, licensed
practitioner, or registered nurse trained in accordance with the requirements
specified by CMS shall personally examine a patient being physically restrained
and/or placed in seclusion and substantiate the need for continuing the use of
seclusion or physical restraint with devices prior to order.
The patient shall be given an explanation of
the reason for the restraint or seclusion, and which would indicate sufficient
behavioral control to discontinue the intervention. The examination shall
include the following unless clinically contraindicated and documented in the
(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
(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 or licensed practitioner;
(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 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 or licensed practitioner shall be contacted as soon as possible if
the restraint or seclusion was ordered by another physician or licensed
(6) Patient care and
(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.
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 or licensed practitioner's order if the patient's
need for reduced stimulus outweighs the need for continued medical
(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 or licensed practitioner'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
(f) The rationale for each episode of seclusion or restraint
shall be clearly documented in the patient's medical record by the
physician or licensed practitioner who examined the patient.
(g) The physician or licensed practitioner 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 MHAS policy MED-19 "Proactive Positive
Intervention Treatment and Safety").
(a) The goals of debriefing are to: (i) minimize the negative
effects of the incident on all involved individuals; and (ii) 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
(i) Assess for any
(ii) Plan next steps for
the patient's care and protection for the remainder of the
(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
(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
(b) Could some
intervention earlier 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
(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
(ii) The review of any
major incidents that resulted in the use of seclusion or
(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
(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
(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.