Rule 5122-26-16.1 | Restraint and seclusion.
(A) The purpose of this rule is to state the specific requirements applicable to restraint and seclusion.
(B) The requirements for the use of mechanical restraint or seclusion do not apply:
(1) To mechanical 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 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.
(C) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definitions apply to this rule:
(1) "Licensed independent practitioner" means an individual who is authorized by the provider to order seclusion and restraint. A licensed independent practitioner includes a "medical practitioner authorized to order seclusion and restraint" as defined in this paragraph, as well as any other practitioner that has ordering seclusion and restraint in their scope of practice.
(2) "Medical practitioner authorized to order seclusion and restraint" means an individual who is authorized by the provider to order seclusion and restraint and who is a psychiatrist or other physician, or a physician's assistant, certified nurse practitioner or clinical nurse specialist authorized to order restraint or seclusion in accordance with their scope of practice and as permitted by applicable law or regulation.
(3) "Order" means written or verbal authorization to implement seclusion or restraint.
(D) Restraint or seclusion will not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is possible. It will be employed for the least amount of time necessary in order that the individual may resume his/her treatment as quickly as possible.
(E) The following are disallowed:
(1) PRN and standing orders for seclusion or restraint.
(2) Restraint and seclusion may not be used simultaneously.
(3) Mechanical restraint may not be used on an individual under age eighteen.
(F) Ordering restraint or seclusion.
(1) For all settings other than a psychiatric residential treatment facility (PRTF), a physical restraint must be authorized by a trained, qualified staff member in accordance with the requirements of the providers' behavioral health national accrediting body or if the organization does not have national accreditation, as identified and approved by the provider's policy. A licensed independent practitioner or practitioner with dependent licensure under supervision will review each incident of physical restrain as soon as possible but not later than seventy-two hours, and if required by national accreditation body, provide an order for the physical restraint in the client records.
(2) For all settings other than a PRTF, seclusion or mechanical restraint orders will be in writing and issued by a licensed independent practitioner or a practitioner with dependent licensure under supervision and include the date and time the order was written or obtained.
(3) In a PRTF, the order for physical restraint, mechanical restraint, or seclusion, will be in writing and issued by a licensed independent practitioner or a practitioner with dependent licensure under supervision and include the date and time the order was written or obtained.
(4) In all circumstances, the order for restraint or seclusion will be the least restrictive intervention that is most likely to be effective in resolving the emergency safety situation based on consultation with staff and specify the type of intervention and the maximum length of time. The order will also note the order is limited to the duration of the emergency safety situation.
(5) Verbal orders.
(a) When an individual authorized to order seclusion and restraint in paragraph (F)(2) or (F)(3) of this rule is not available in person to order restraint or seclusion or immediate intervention is required, agency policy may permit staff to obtain a verbal order from a licensed independent practitioner or a practitioner with dependent licensure under supervision while the restraint or seclusion is being initiated by staff or immediately after the intervention ends.
(b) The verbal order will be signed by a licensed independent practitioner or a practitioner with dependent licensure under supervision or independent licensure, at least either by the end of the work day or in a residential setting during the next scheduled shift.
(6) Written and verbal orders may be written for a maximum of:
(a) Two hours for restraint or seclusion of adults eighteen years of age or older;
(b) One hour for restraint or seclusion of children and adolescents age nine through seventeen; or
(c) Thirty minutes for restraint or seclusion of children under age nine.
(7) If restraint is necessary as a means of safely transporting an individual to seclusion, a separate order is not needed. However, the initial order for the seclusion will include the physical transport restraint and be consistent with the standards for restraint/seclusion orders.
(8) If the restraint or seclusion continues past the original time in the order, staff will contact the individual who issued the original order who will issue a new written or verbal order if seclusion or restraint is to be continued. In a PRTF, a licensed practical nurse or registered nurse will be the person who contacts the medical practitioner, and a restraint or seclusion may not be continued past the time limits in paragraph (F)(6) of this rule.
(9) If the restraint or seclusion episode is concluded, and the client's behavior necessitates initiating another restraint or seclusion, then a new order will be obtained, even if the ending time of the original order has not passed.
(G) Implementation of restraint or seclusion.
(1) Restraint or seclusion will be discontinued at the earliest possible time, regardless of the length of time identified in the order.
(2) A trained and qualified practitioner with appropriate training in seclusion and restraint and in accordance with their scope of practice will conduct assessment of the physical and psychological well-being of the individual in accordance with the provider's national accrediting body. If not nationally accredited, a licensed practitioner will conduct the assessment within two hours of the initiation of the seclusion or restraint intervention. The assessment will either be conducted in person, face-to-face, or via interactive videoconferencing based on the individual's clinical and medical needs. Interactive videoconferencing will only be used if appropriate for the individual. In a PRTF, this assessment will be in person, face-to-face, within one hour of the initiation of the seclusion or restraint intervention and conducted by a medical practitioner authorized to order seclusion and restraint or a registered nurse. The assessment is to be conducted even if the seclusion or restraint intervention is ended before one hour. The assessment is to include, but is not limited to:
(a) The individual 's physical and psychological status;
(b) The individual 's behavior;
(c) The appropriateness of the intervention measures; and
(d) Any complications resulting from the intervention.
(3) Monitoring while in and immediately after seclusion or restraint.
(a) Restraint.
(i) A staff trained in the use of restraint will be physically present, continually assessing and monitoring the physical and psychological well-being of the individual and the safe use throughout the duration of the intervention.
(ii) Documentation of the condition of the person will 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 will address at a minimum, attention to respiration, the individual's physical status and behavior, the need for continued restraint, and other needs as necessary, and the appropriate actions taken.
(b) Seclusion.
(i) A staff trained in the use of seclusion will be physically present either in or immediately outside the seclusion room, continually assessing and monitoring the physical and psychological well-being of the individual and the safe use throughout the duration of the intervention.
(ii) Documentation of the condition of the person will 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 will address at a minimum, attention to respiration, the individual's physical status and behavior, the need for continued seclusion, and other needs as necessary, and the appropriate actions taken.
(iii) If seclusion lasts longer than ten minutes, the person will be given adequate access to the restroom and water at least every thirty minutes.
(c) At the conclusion of the restraint or seclusion, a licensed medical staff will immediately check the resident for any injuries, evaluate the individual's psychological well-being and document the results.
(4) Staff will assure that a client injured during a restraint or seclusion intervention receives immediate medical treatment that is appropriate for the specific injury, including transfer to a hospital for evaluation and treatment if needed.
(5) Transitional holds are not seclusion or restraint, and are not subject to this rule.
(H) Notification of the use of seclusion or restraint.
(1) If the client is a minor, the provider will notify the parent(s), custodian(s) or legal guardian(s) of the individual who has been restrained or placed in seclusion as soon as possible after the initiation of each episode; and in a PRTF the notification will occur within twenty-four hours of the intervention..
(2) If the client is an adult, the provider will notify the client's guardian, when applicable, or family or significant other when the client has given their consent for such notification, within twenty-four hours of initiation of each episode.
(3) The provider will document in the client's record that the notification was made, including the date and time of notification, the name of the person(s) notified and the name of the staff person providing the notification.
(I) Debriefing.
(1) Within twenty-four hours after the use of restraint or seclusion, all staff directly involved in a seclusion or restraint intervention and the client will have a face-to-face discussion. This discussion will include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the client. Other staff and the client parents, custodian or guardian may participate in the discussion when it is deemed appropriate by the provider.
(a) The discussion will include the circumstances resulting in the use of seclusion or restraint.
(b) The discussion will include identifying techniques and tools that might help the individual regulate their own behavior in the future and modifications to the individual's crisis plan.
(c) The outcome and any injuries that may have resulted from the use of seclusion or restraint.
(d) The discussion will include any other element as required by the provider's national accrediting body as part of a debriefing process. This may include a separate staff debriefing.
(e) The debriefing will be conducted in a language understood by the client, and their parent, custodian, or guardian.
(f) In non-PRTF settings the client debriefing may be delayed if the client refuses, is not available, or the debriefing is clinically not appropriate at that time. The debriefing will be conducted as soon as practical and prudent.
(2) A PRTF, in addition to the briefing set forth in paragraph (I)(1) of this rule, will conduct a staff only debriefing session within twenty-four hours after the use of restraint or seclusion. The debriefing will include all staff involved in the intervention and appropriate supervisory and administrative staff. The debriefing session will include at a minimum a review and discussion of:
(a) The situation that necessitated the intervention, including a discussion of the precipitating factors that led up to the intervention;
(b) Alternative techniques that might have prevented the use of the restraint or seclusion;
(c) The procedures, if any, that staff are to implement to prevent any recurrence of the use of restraint or seclusion; and
(d) The outcome and any injuries that may have resulted from the use of restraint or seclusion.
(3) Staff will document in the record for each client who is debriefed the number of debriefing sessions that took place, the names of staff who were present for the debriefing, names of staff that were excused from the debriefing, and any changes to the individual's treatment plan that result from the debriefings.
(4) Debriefings may be conducted via virtual means.
(J) Staff involved in a restraint or seclusion intervention that results in an injury to a client or staff will meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent future injuries. This documentation may be included with the client's debriefing or contained elsewhere. The plan to prevent future injuries is to include at a minimum attention to revised procedures, and new or additional staff training.
(K) Documentation.
Staff will document the intervention in the client's ICR. That documentation will be completed by either the end of the work day or the end of the shift in which the intervention occurs. In a residential setting if the intervention does not end during the shift in which it began, documentation will be completed during the shift in which it ends. Documentation will include all of the following:
(1) Each order for restraint or seclusion as set forth in paragraph (F) of this rule.
(2) The date, day of week, time and shift the restraint or seclusion began and the duration.
(3) The type of method, including type of physical hold or mechanical restraint utilized.
(4) The client's behavior that resulted in the client being restrained or put in seclusion.
(5) Attempts to offer alternatives to the client based upon their crisis plan or de-escalation techniques, as applicable
(6) Each attempt to use less restrictive interventions, and the results.
(7) The time and results of the assessment in paragraph (G)(2) of this rule.
(8) The time and results of the on-going monitoring in paragraph (G)(3) of this rule.
(9) The name of all staff involved in the restraint or seclusion, including the staff that conducts the assessment and the staff who ordered the restraint or seclusion.
(10) Any psychotropic medications utilized during the restraint or seclusion.
(11) All injuries that occur as a result of the restraint or seclusion, including injuries to staff resulting from the intervention. Detailed information about any staff injury may be maintained outside the client's ICR. The appropriate actions taken for any injuries noted will also be documented.
(L) Seclusion room requirements.
The type of room in which seclusion is employed will ensure:
(1) Appropriate temperature control, ventilation and lighting;
(2) Safe wall and ceiling fixtures, with no 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.
(M) Clinically appropriate reason for the inability to implement any portion of this rule will be documented in the clinical record, and will be addressed in any staff de-briefing of the episode and in the provider's performance improvement process.
Last updated October 20, 2023 at 12:59 AM
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