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Procedure UNM Health Sciences Center

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Procedure UNM Health Sciences Center Powered By Docstoc
					                                                           Applies To: All HSC Hospitals
                                                           Component(s): All psychiatric inpatient and residential
                                                           treatment units
                                                           Responsible Department: Behavioral Health Education

 Title: Use of   Restraint and/or Seclusion for Behavioral                               Procedure
 Reasons
 Patient Age Group:          ( ) N/A        ( ) All Ages       ( ) Newborns        ( X) Pediatric      (X ) Adult


DESCRIPTION/OVERVIEW
The University of New Mexico Health Sciences Center (UNMHSC) Hospitals and staff strive to
deliver patient care free from restraint or seclusion. Respect for patient rights, safety and dignity
is the basis for this statement.

We recognize that providing a safe environment and preventing injury are essential to obtaining
desired outcomes. Restraint and seclusion use is limited to clinically justified circumstances
where it is necessary to ensure the immediate physical safety of the patient, a staff member or
others, and other less restrictive interventions have been determined to be ineffective or
inappropriate to protect the patient, a staff member or others from harm. We recognize and
support that imposing a restraint or seclusion for convenience, discipline, retaliation, or coercion
is never acceptable, and that each patient is to be treated with respect and dignity. Therefore,
even where restraint and seclusion are necessary, they must be discontinued at the earliest
possible time.

REFERENCES
     The Joint Commission
     Center for Medicare/Medicaid Services Hospital Conditions of Participation
     Center for Medicare/Medicaid Psychiatric Hospital Conditions of Participation
     New Mexico Children, Youth and Family Department
     New Mexico Mental Health and Developmental Disabilities Act
     New Mexico Children‟s Mental Health and Developmental Disabilities Act
     Medical Staff Policy and Procedure: Restraints Use Section-Treatment-14TX
     Security Policy: Prisoner Restraints
     UNM Children‟s Psychiatric Center Guideline: Crisis Response Team
     UNM Children‟s Psychiatric Center Guideline: Behavior Management Guideline
     UNM Psychiatric Center Guideline: Crisis Response Team
     UNM Psychiatric Center Guideline: Crisis Response Team Performance
       Improvement Plan
     UNM Psychiatric Center Guideline: Crisis Team Certification
     UH Entrapment Prevention Guideline
     UH Policy: Sentinel Events and Near Misses
     UH Policy: Variance Reporting
     UH Policy: Outcomes Disclosure
     Health Sciences Center Patient Centered Performance Improvement Plan



_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 1 of 15
AREAS OF RESPONSIBILITY
   Nurses – Assess patient before, during and after the application of restraint or seclusion.
    Use clinical judgment to determine optimal patient positioning during mechanical
    restraint intervention. Perform face-to-face assessment of patient within one hour of
    initiation of restraint or seclusion. Assist patient to de-escalate his/her behaviors. Use
    clinical judgment to determine if intervention can be discontinued.
   Mental Health Technicians and/or Mental Health Associates - Provide care for patient
    admitted to behavioral health inpatient units who may require the use of restraint or
    seclusion. Assist patient to de-escalate his/her behaviors.
   Members of Behavioral Health Crisis Team – Assist patient to de-escalate his/her
    behaviors and, if patient continues to be at risk of harm to self or others, apply restraint or
    seclusion.
   Physicians and other Licensed Independent Practitioners – Assess need for restraint
    or seclusion of patient to ensure safety of patient or others. Order the use of restraint or
    seclusion when indicated.

PROCEDURE:
1) Assessment:
Assess the need for restraint or seclusion to ensure the immediate physical safety of the patient, a
staff member or others, and where other less restrictive interventions have been determined to be
ineffective.
2) Intervention:
    a) Review the patient‟s Individual Crisis Management Plan and Psychiatric Advance
        Directives (as available) for information regarding preferred means for de-escalation of
        behaviors and any medical or psychiatric history that may affect the use of de-escalation
        techniques including restraint or seclusion.
        i) Consider alternative interventions that may obviate need for restraint or seclusion
            (1)         Approach in slow, non-threatening manner
            (2)         Maintain a calm attitude
            (3)         Reorient patient
            (4)         Place patient closer to nurse station
            (5)         Pain/comfort measures
            (6)         Verbal de-escalation
            (7)         Decrease environmental noise as much as possible
            (8)         Frequent contact with staff/family
            (9)         Use diversional activities
            (10)        Use of sitter/family at bedside
            (11)        Provide structured approach
  b) The use of restraint or seclusion must be ordered by a physician or other licensed
      independent practitioner (LIP) who is responsible for the care of the patient and is
      permitted by State law and hospital policy to order restraint or seclusion and trained in the
      use of such emergency safety interventions. An order for restraint or seclusion must never
      be written as a standing order or on an as needed basis (PRN). The type or technique of
      restraint or seclusion must be the least restrictive intervention that will be effective to
      protect the patient, a staff member or others from harm. The restraint or seclusion must be

_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 2 of 15
     discontinued at the earliest possible time regardless of the maximum length of time
     identified in the order.
       i) Order is time limited with maximum time as follows:
            (i) Adults - Maximum time of four (4) hours
            (ii) Children and adolescents - Maximum time of one (1) hour
       ii) If the patient‟s Attending Physician is available, he/she must order the restraint or
            seclusion. If the patient‟s Attending Physician did not order the restraint or seclusion,
            he/she must be consulted as soon as possible. Such consultation may include verbal,
            telephone or email communication and must be documented in the patient‟s chart.
       iii) Each order for restraint or seclusion must include:
            (i) Name of ordering physician or other LIP permitted by law and hospital policy to
                 order restraint or seclusion;
            (ii) Date and time order was obtained;
            (iii)The type of emergency safety intervention ordered, including length of time such
                 use of intervention is authorized by physician or other LIP
  c) A physician or other LIP or an appropriately trained registered nurse conducts a face-to-
     face assessment of the patient within one hour after the initiation of restraint or seclusion
     used for management of violent or self-destructive behavior that jeopardizes the immediate
     physical safety of the patient, a staff member, or others. Such assessment must include an
     evaluation of:
            (i) The patient‟s immediate situation (physical and psychological status);
            (ii) The patient‟s reaction to the restraint or seclusion (patient‟s behavior);
            (iii)The patient‟s medical and behavioral condition and any complications resulting
                 from the intervention; and
            (iv) The appropriateness of and need to continue or discontinue the restraint or
                 seclusion.
       i) If a registered nurse conducts a face-to-face assessment, he/she must be a nurse other
       than the nurse initiating the intervention. The nurse conducting the assessment must
       consult with the patient‟s Attending Physician or other LIP responsible for the patient‟s
       care as soon as possible but not later than one hour after completion of the assessment.
       Where the intervention is discontinued during that one-hour period, the nurse must still
       conduct the face-to-face assessment of the patient and consult with the Attending
       Physician or other LIP responsible for the patient‟s care.
       ii) The nurse consultation with the Attending Physician or other LIP shall include, but is
            not limited to, a report of:
            (i) The patient‟s immediate situation (physical and psychological status);
            (ii) The patient‟s reaction to the restraint or seclusion (patient‟s behavior);
            (iii)The patient‟s medical and behavioral condition and any complications resulting
                 from the intervention; and
            (iv) The appropriateness of and need to continue or discontinue the restraint or
                 seclusion
       iii) Each order for restraint or seclusion used for the management of violent or self-
            destructive behavior that jeopardizes the immediate physical safety of the patient, a
            staff member or others may only be renewed through consultation with the Attending
            Physician or other LIP in accordance with the following time limitations for up to a
            total of 24 hours:


_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 3 of 15
             (i) Adults – Maximum time of order is four (4) hours
             (ii) Children and adolescents – Maximum time of order is one (1) hour
      After 24 hours, only the Attending Physician or other LIP responsible for the patient‟s care
      may write a new order for restraint of seclusion after such Attending Physician or other LIP
      has seen and assessed the patient.
  d) If the Attending Physician or other LIP responsible for the patient‟s care is not available to
      provide an order, a Registered Nurse (RN) or appropriately trained staff member may
      initiate restraint or seclusion.
        i) The RN will:
             (1) Advise Attending Physician or other LIP of patient‟s condition within 15 minutes
                  of initiation of restraint or seclusion.
             (2) Request a telephone time-limited order for restraint or seclusion.
                  (a) This order must be received within one hour of initiation of restraint or
                      seclusion and signed within 24 hours of initiation of restraint or seclusion.
                  (b) RN or licensed practical nurse (LPN) is permitted to receive telephone orders
                      for restraint or seclusion.
             (3) Verbal orders for restraint or seclusion are not permitted.
    f) The Attending Physician or other LIP who ordered the restraint or seclusion must be
        available to staff for consultation throughout the entire period that the patient is in
        restraint or seclusion.
    g) The use of restraint or seclusion is implemented in accordance with a written
        modification to the patient‟s plan of care.
    h) The use of restraint or seclusion is implemented in the least restrictive manner possible
        by Behavioral Health Crisis team members and must be in accordance with safe,
        appropriate restraint and seclusion techniques in accordance with hospital policy, and
        includes but is not limited to consideration of information learned from the patient‟s
        initial and continued assessments. Restraint or seclusion must be performed in a manner
        that is safe, proportionate, and appropriate to the severity of the behavior; chronological
        and developmental age; size; gender; physical, medical and psychiatric condition; and
        personal history (including physical or sexual abuse).
        i) Crisis Response Team Members will remove all potentially dangerous items
             considered a safety risk from the patient, such as pagers, watches, and sharp objects
             from their person prior to becoming involved in any intervention.
        ii) The Crisis Response Team Leader will explain to the patient the reasons and benefits
             for the use of restraint or seclusion, as well as the criteria for discontinued use of
             restraint or seclusion if appropriate at that time.
        iii) Verbal intervention during the restraint or seclusion procedure should focus on
             providing instructions to the patient necessary for maintaining safety and assisting the
             patient to regain self-control.
        iv) Prior to placing the patient in restraint, ensure proper body alignment.
             (1) The RN or LIP assesses the patient to determine best placement for restraint with
                  consideration of the following:
                  (a) Patients who have respiratory compromise (such as asthma, COPD,
                      emphysema) or patients who are obese may benefit from being restrained in a
                      side lying position with both wrists placed forward OR in a supine position. If
                      possible, the head of the bed is raised.


_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 4 of 15
                 (b) Patients who are known to be pregnant are restrained in a left side-lying
                     position with both wrists placed forward. If possible, the head of the bed is
                     raised.
        v) Two (2) staff members will check placement and tightness of five point mechanical
             restraints. All such use of mechanical restraints and the reasons for such use must be
             fully documented in the patient‟s chart.
        vi) If the use of restraint or seclusion is determined to be necessary beyond the time
             provided in the order for restraint or seclusion, the RN must contact the ordering
             physician or other LIP for further instructions.
    j) The use of restraint or seclusion must be discontinued at the earliest possible time,
        regardless of the length of time identified in the order for restraint or seclusion.
    k) An LIP, RN or other appropriately trained staff may discontinue restraint or seclusion
        based on an assessment of the patient‟s condition and continued need for restraint or
        seclusion. However, if staff discontinues restraint or seclusion, neither may be
        reinstituted without a new order from a physician or other LIP and subsequent
        consultation with the Attending Physician if he/she does not write the new order.
    l) Restraint and seclusion may not be used simultaneously.
    m) The condition of the patient who is in restraint or seclusion must be monitored, assessed
        and re-evaluated by a physician, LIP or other appropriately trained staff who have
        completed the training criteria specified in this policy throughout the duration of the
        emergency safety intervention.
        i) During the period of restraint or seclusion, a physician or other LIP or appropriately
            trained staff must monitor a patient by conducting an in-person re-evaluation at least
            every hour for children and adolescents and every eight (8) hours for adults.
        ii) Mental health technicians who have completed training in safe application of
            restraint, seclusion, CPI, and first aid may monitor the patient while in restraint or
            seclusion.
        iii) Such monitoring, assessment and re-evaluation includes but is not limited to:
             (1)         Readiness for discontinuation of restraint or seclusion intervention
             (2)         Patient activity
             (3)         Extremity condition (i.e., skin integrity)
             (4)         Signs of physical distress or injury
             (5)         Signs of psychological distress
             (6)         Vital signs
             (7)         Respiratory status
             (8)         Circulatory status
             (9)         Need for fluids
             (10)        Hygiene needs
             (11)        Toileting needs
             (12)        Nutritional needs
    n) Temporary discontinuance of restraint or seclusion may be required in order to provide
        the required monitoring, assessment and/or re-evaluation.
    o) Additional reassessment by an RN occurs every one (1) hour for children and adolescents
        and every two (2) hours for adults.
    p) As soon as it is determined that the patient no longer presents a risk of harm to the patient,
       a staff member or others, the restraint or seclusion must be discontinued, regardless of the
       length of time identified in the order for restraint or seclusion.
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 5 of 15
      i) Staff will remove 5-point restraints one or two restraints at a time. Under no
           circumstances will the patient be left with only one limb secured.
      ii) Staff removes restraints one at a time until the last limb restraint is removed
           simultaneously with the torso restraint.
      iii) An RN will assess the patient‟s physical, psychiatric and mental status at the
           conclusion of the use of restraint or seclusion.
      iv) A physician or other LIP permitted by law and hospital policy to evaluate a patient
           and trained in the use of emergency safety interventions must evaluate the patient
           immediately after the patient is removed from restraint or seclusion.
3) Documentation
   a) Documentation of the use of restraint or seclusion must be made in the patient‟s medical
      record and available for inspection by the patient or, in the case of a minor, the patient‟s
      parent(s) or legal guardian.
   b) Documentation must include the following:
      i)       The one-hour face-to-face medical and behavioral evaluation;
      ii)      Description of patient‟s behavior and the intervention used;
      iii)     Alternative or other less restrictive interventions attempted (as applicable) and/or
               determined to be in appropriate;
      iv)      Patient‟s condition or symptom(s) and emergency safety situation that warranted
               use of restraint or seclusion;
      v)       Patient‟s response to the intervention used, including the rationale for continued
               use or intervention;
      vi)      Date and time the Attending Physician was consulted regarding the use of
               restraint or seclusion if that Attending Physician did not order the restraint or
               seclusion;
      vii)     Restraint or seclusion order, including date and time order obtained and specific
               type of intervention and length of time authorized, and signed by the physician or
               other LIP ordering the restraint or seclusion as soon as possible;
      viii) Restraint or seclusion flow sheet, including times intervention began and was
               discontinued and the names of staff who observed behavior prompting use of
               restraint or seclusion and/or who were involved in implementing and monitoring
               the intervention;
      ix)      Patient debriefing form; and
      x)       Staff debriefing form;
   c) The hospital must maintain a record of each emergency safety situations, interventions
      used in response, and outcomes.
4) Debriefing
   a) The patient, patient family members as appropriate, and staff participate in a debriefing
      session regarding the use of restraint or seclusion within 24 hours after the period of
      restraint or seclusion. The debriefing shall be documented in the patient‟s chart and
      incorporated into the next treatment plan review.
   b) The staff member assigned to participate in debriefing is selected by the team captain
      based upon the staff member‟s rapport with the patient and patient‟s family and the
      ability to complete the debriefing in a timely fashion
      The purpose of debriefing is to:
           (1) Identify what led to the patient‟s condition or symptom(s) warranting restraint or
               seclusion.
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 6 of 15
           (2) Confirm that the patient‟s physical well being, psychological comfort and right to
               privacy were addressed.
           (3) Provide counseling to the patient for any physical or psychological trauma that
               may have resulted from the use of restraint or seclusion
   c) The Crisis Response Team leader will facilitate a review and discussion of the use of
      restraint or seclusion with the staff who participated in the intervention and other staff
      (for example, clinical or administrative) as appropriate within 24 hours of the period of
      restraint or seclusion. Such review and discussion is documented in the staff debriefing
      form.
4) Staff Training
   a) All staff with direct patient contact must receive training by qualified individuals and
      demonstrate competency in the application of restraints, implementation of seclusion,
      monitoring, assessment and providing care for a patient in restraint or seclusion
      i) Before performing any intervention involving restraint or seclusion;
      ii) As part of orientation; and
      iii) Subsequently on a periodic basis consistent with hospital policy.
   b) All staff with direct patient contact must have ongoing education, training and be able to
      demonstrate knowledge of managing emergency safety situations through training
      exercises designed to test their competencies in:
      i) Techniques to identify staff and patient behaviors, events and environmental factors
           that may trigger emergency safety situations necessitating the use of restraint or
           seclusion;
      ii) The use of nonphysical intervention skills such as de-escalation, mediation conflict
           resolution, active listening, and verbal and observational methods, to prevent
           emergency safety situations;
      iii) Choosing the least restrictive intervention based on an individualized assessment of
           the patient‟s medical, behavioral status or condition;
      iv) The safe application and use of all types of restraint or seclusion used in the hospital,
           including training in how to recognize and respond to signs of physical and
           psychological distress (i.e. position asphyxia);
      v) Clinical identification of specific behavioral changes that indicate the use of restraint
           or seclusion is no longer necessary;
      vi) Monitoring the physical and psychological well-being of the patient who is restrained
           or secluded, including but not limited to respiratory and circulatory status, skin
           integrity, vital signs, and any special requirements associated with the one hour fact-
           to-face evaluation; and
      vii) Use of first aid techniques and certification in the use of cardiopulmonary
           resuscitation, including required periodic recertification.
   c) All staff with direct patient contact must have the above referenced training annually and
      as needed for additional support
   d) All staff with direct patient contact must be certified in Basic Life Support (including
      cardiopulmonary resuscitation) and First Aid prior to working with patients
      independently and must obtain periodic recertification in cardiopulmonary resuscitation.
   e) Physicians and other LIP who order restraint or seclusion must have demonstrated
      knowledge of the hospital policy regarding the use of restraint or seclusion
5) Staffing levels


_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 7 of 15
   a) Staffing levels are based on census and acuity and are structured to decrease the need for
       emergency safety interventions such as the use of restraint or seclusion.
6) Reporting
   a) Extended or multiple episodes of restraint or seclusion for one patient
       i) Clinical leaders, such as the medical director or unit director, are notified of instances
            where a patient remains in restraint or seclusion for more than 12 hours or
            experiences 2 or more separate periods of restraint and/or seclusion of any duration
            within 12 hours
       ii) Thereafter, clinical leaders are notified every 24 hours if either of the above
            conditions continues
   b) Patient deaths associated with use of restraint or seclusion
       i) The Executive Director or designee must report to the Centers for Medicare and
            Medicaid Services (CMS)
            (1) each death of a patient that occurs while the patient is in restraint or seclusion;
            (2) each death of a patient that occurs within 24 hours after removal of restraint or
                seclusion; or
            (3) each death of a patient that occurs within one (1) week after restraint or seclusion
                where it is reasonable to assume that the use of restraint or seclusion contributed
                directly or indirectly to the patient‟s death (i.e., includes, but is not limited to,
                deaths related to restriction of movement for prolonged periods of time, or death
                related to chest compression, restriction of breathing or asphyxiation).
        ii) Each patient death referenced in ii) above must be reported to CMS by telephone as
            soon as possible after the death has occurred but no later than 4 hours after
            knowledge of the death.
       iii) Staff must document in the patient‟s medical records the date and time the death was
            reported to CMS.
       iv) Reports are provided to the following agencies:
            (1) Centers for Medicare and Medicaid Services Regional Office
                Licensing and Certification Unit
                3401 Pan American Fwy NE
                Albuquerque New Mexico, 87107
            (2) Value Options for patients who are Value Options insured – reporting form is
                included in addendum.
    c) Patient injuries associated with use of restraint or seclusion
       i) Serious patient injuries of unknown origin are investigated and reported pursuant to
            any applicable restraint or seclusion reporting requirements if the origin is not
            determined.
       ii) The Executive Director or designee provides information to the patient and/or
            patient‟s family members concerning the patient‟s serious injury. Such information
            includes but is not limited to:
            (1) nature and extent of injury and necessary treatment; and
            (2) that necessary treatment has been received
   d) Staff injuries
       i) Staff injuries secondary to patient assault or the application of restraint or seclusion
           are reported to:
            (1) Patient Safety Net
            (2) Occupation Health
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 8 of 15
          (3) Direct supervisor
      ii) Staff involved in restraint or seclusion that results in a patient and/or staff injury must
      meet with supervisory staff to evaluate the circumstances that caused or contributed to
      the injury and to develop a plan to prevent future injuries.
7) Patient and Family Communication for Patients admitted to Behavioral Health
   Inpatient or Residential Treatment Units
   a) Upon admission, the RN or MHT shall provide to the patient, or in the case of a minor to
      his/her parents or legal guardian, a written statement of the policy and procedures on the
      use of restraint and seclusion during an emergency safety situation. This information
      includes the process for reporting a complaint or grievance, as well as contact
      information for the appropriate State Protection and Advocacy System.
   b) A written acknowledgment shall be obtained from the patient, or in the case of a minor
      from his/her parents or legal guardian, that he/she has been informed of the policy and
      procedures on the use of restraint or seclusion during an emergency safety situation. Staff
      must file the acknowledgement in the patient‟s chart.
   c) In cases where an adult patient has consented to family members being informed about
      his/her care, treatment and services, and the family has agreed to be notified, staff must
      attempt to contact the family with 24 hours to notify them of the use of restraint or
      seclusion.

 UNIT OR AREA SPECIFIC REQUIREMENTs

 Children’s Psychiatric Center
 1) In addition to the procedures outlined in the general text above, the following procedures
 are also required:
 2) Notification of parent(s) or legal guardian when a child/adolescent patient is placed in
    restraint or seclusion
    a) The clinician, physician or RN will notify the parent(s) or legal guardian immediately each
        time a child/adolescent is placed in restraint or seclusion. The date and time of notification
        and name of the staff person making the notification must be documented in the patient‟s
        chart.
    b) If the parent(s) or legal guardian is not reasonably available, staff shall document in the
        patient‟s chart all attempts to notify the parent(s) or legal guardian and shall send a written
        notification within one (1) business day.
    c) If the parent(s) do not want to be contacted or notified, the clinician, physician or RN
        documents that information in the contact information section of the patient‟s chart
    d) All attempts and means of contact of the parent(s) or legal guardian are documented in the
        progress notes of the patient‟s chart and communicated verbally to the treatment team.

 3) Monitoring of child/adolescent patient in restraint or seclusion
    a) Physical restraint or seclusion shall be used only by a mental health or developmental
       disabilities professional trained in the appropriate use of physical restraint or seclusion.
    b) A physical restraint shall be applied only with such reasonable force as is necessary to
       protect the patient or other person from imminent and serious physical harm.
    c) At a minimum, a seclusion room must:
           (i) be free of objects and fixtures with which a patient could self-inflict bodily
                harm (i.e., unprotected light fixtures and electrical outlets;
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                 Page 9 of 15
             (ii) provide the mental health or developmental disabilities professional an adequate
                   and continuous view of the patient from an adjacent area; and
             (iii) provide adequate lighting and ventilation.
     b) During seclusion, the patient shall be:
             (i) viewed by appropriately trained staff at all times; and
             (ii) provided with an explanation of the behavior resulting in seclusion and instructions
                   on the behavior required to discontinue seclusion.
     c) A mental health or developmental disabilities professional trained in the use of restraint or
         seclusion must be physically present (in or outside the seclusion room), continually assessing
         and monitoring the physical and psychological well-being of the patient and the safe use of
         restraint or seclusion throughout the duration or restraint or seclusion. Video monitoring
        does not meet this requirement as to the monitoring of a patient in seclusion.
     d) A mental health or developmental disabilities professional permitted to evaluate a patient‟s
         well-being and trained in the use of restraint or seclusion, must evaluate the patient‟s well-
         being immediately after the resident is removed from restraint or seclusion.

 3) Documentation of restraint or seclusion of child/adolescent patient
    a) When a patient is in restraint or seclusion, the mental health or developmental disabilities
       professional shall document:
          (i) any less intrusive interventions attempted or determined inappropriate;
          (ii) the precipitating event immediately preceding the behavior that prompted the use of
                restraint or seclusion;
          (iii) the behavior that prompted the use of a restraint or seclusion;
          (iv) the names of the mental health or developmental disabilities professional who
                observed the behavior that prompted the use of restraint or seclusion;
          (v) the names of the staff members implementing and monitoring the use of restraint or
                 seclusion; and
          (vi) a description of the restraint or seclusion, including type and length of time used,
                 the behavior during and in response to the restraint or seclusion, and the name of the
                 supervisor informed of the use of restraint or seclusion.

     b) Such documentation shall be maintained in the patient‟s chart and available for inspection by
        the patient‟s parent(s) or legal guardian.

 4) Debriefing of child/adolescent patient and staff:
    a) Debriefing of the patient - A face-to-face discussion between patient and all staff involved in
       intervention (except staff member whose presence may jeopardize well-being of patient)
       occurs within 24 hours of the removal of the restraint or seclusion.
            (i) Parent(s) or legal guardian are notified of the debriefing and given an opportunity to
                 participate as therapeutically indicated Other staff may also attend as appropriate.
            (ii) Discussion includes the circumstances warranting the use of restraint or seclusion
                 and strategies for the patient, a staff member or others that could obviate the need
                 for future use of restraint or seclusion
           (iii) Documentation of the debriefing is included in the Individual Crisis Management
                 Plan Update and includes:
                   (1) full names of the staff members involved in the restraint or seclusion; and
                   (2) full names of the staff members who participated in the debriefing of patient
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 10 of 15
     b) Debriefing of the staff - A discussion with the treatment team and/or other staff occurs
        within 24 hours of the removal of the restraint or seclusion to review and revise treatment
        plan as appropriate
              (i) Includes staff involved in the intervention and appropriate supervisory and
                    administrative staff
              (ii) Discussion includes review and discussion of alternative techniques that might
                    have prevented use of the restraint or seclusion; procedures, if any, staff are to
                    implement to prevent the future use of restraint or seclusion; and the outcome of
                    the intervention, including any injuries that may have resulted from the use of
                    restraint or seclusion.
              (iii) Documentation of the staff debriefing is included in the Individual Crisis
                    Management Plan Update and includes:
                    (1) full names of the staff members who participated in the staff debriefing event

 4) Staff training
    a) A mental health or developmental disabilities professional who administers restraint or
       seclusion shall receive training in current professionally accepted practices and standards
       regarding:
                   (i) positive behavior interventions strategies and supports;
                   (ii) functional behavior assessment and behavior intervention planning;
                   (iii) prevention of self-injurious behaviors;
                   (iv) methods for identifying and defusing potentially dangerous behavior; and
                   (v) restraint and seclusion, to the extent that each may be used in the treatment
                         setting.

     b) All staff who participate in the use of restraint or seclusion must demonstrate competencies
        in the safe use of restraint, seclusion and behavior management on a semiannual basis, and
        must demonstrate competencies in cardiopulmonary resuscitation on an annual basis,
        including obtaining any required recertification thereof.

 5) Medical treatment and notification of parent(s) or legal guardian when a child/adolescent
     is injured in restraint or seclusion
    a) Staff must seek immediate medical treatment for a patient injured as a result of restraint or
         seclusion.
    b) The clinician or physician will notify the patient‟s parent(s) or guardian as soon as possible
         but no later than within 24 hours after an injury. Information to be provided includes the
         nature of the injury and the treatment provided.
    c) Staff shall document in the patient‟s chart all injuries that occur as a result of restraint or
         seclusion, including injuries to staff resulting from the intervention.

 6) Reporting of death or serious injury to child/adolescent patient in restraint or seclusion
    a) Staff must report each serious occurrence involving a patient by no later than close of
       business the next business day after a serious occurrence to:
       (1) New Mexico Human Services Department
            Medicaid Assistance Division
            P.O. Box 2348
            Santa Fe, NM 87504-2348
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 11 of 15
                (505) 827-7750
           (2) New Mexico Protection and Advocacy Service
                1720 Louisiana Blvd. Suite 204, Albuquerque NM 87110
                (505) 256-3100              or     1-800-432-4682
            Staff must also report patient deaths by no later than close of business of the next business
                day to:
                Centers for Medicare and Medicaid Regional Office
                Licensing and Certification Unit
                3401 Pan American Fwy NE
                Albuquerque New Mexico, 87107
                (505)
      b)    Serious occurrences that must be reported include a patient‟s death, a patient‟s suicide
            attempt, or other serious injury to a patient (any significant impairment of the physical
            conditions as determined by qualified medical personnel, including but not limited to burns,
            lacerations, bone factures, substantial hematoma, and injuries to internal organs, whether or
            not self-inflicted or inflicted by someone else).
      c)    The report must include the name of the patient involved in the serious occurrence, a
            description of the occurrence, and the name, street address, and telephone number of the
             facility.
      d)    Staff must document in the patient‟s chart that the serious occurrence was reported to both
            the State Medicaid Agency and State Protection and Advocacy Service, stating the name of
            the person to whom the occurrence was reported, and a copy of the report must also be
            maintained in the patient‟s chart.
     e)    Staff must document in the patient‟s chart that a patient‟s death was reported to the CMS
           Regional Office.


DEFINITIONS:
  Adult: A person who is eighteen (18) years of age or older.
  Attending physician: The physician who has the primary responsibility for the care of the
  patient at a given time or with regard to a particular therapy or treatment. The attending
  physician supervises other members of the treatment team and includes an “on-call”
  physician providing coverage to care for the patient when the attending physician is
  unavailable.
  Behavioral restraint: A restraint used during periods of disorientation, perceptual
  alterations, and/or mental impairment rendering a patient harmful to self or others, when less
  restrictive interventions have been determined to be ineffective to protect the patient, a staff
  member or others.
  Chemical Restraint: A drug or medication used to control the patient‟s behavior in a way
  that reduces the safety risk to the patient or others, or that temporarily restricts the patient‟s
  freedom of movement and is not a standard treatment or dosage for the patient‟s medical or
  psychiatric condition.
  Child/Adolescent: A person who is seventeen (17) years of age or younger.
  Crisis Response Team: Teams of specially trained behavioral health staff who provide
  supportive care for individuals in a psychiatric crisis that may require the use of restraints or
  seclusion at the University of New Mexico Psychiatric Center and at the University of New
  Mexico Children‟s Psychiatric Center.
_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 12 of 15
        Team Members are certified through completing Crisis Intervention Training with an
         annual re-certification.
     Team Members are staff members who are on the Crisis Team and who attend regular
         Team Meetings.
    Emergency Safety Intervention: Use of restraint or seclusion as an immediate response to
    an emergency safety situation. Emergency safety situation means unanticipated behavior of
    the patient that places patient, staff members or others at serious threat of violence or injury
    if no intervention occurs and that calls for emergency safety intervention as defined above.
    Least restrictive interventions to Most Restrictive Interventions: Interventions that assist
    to de-escalate a patient‟s behavior may be considered on a continuum from least to most
    restrictive interventions. Least restrictive include those interventions that provide the client
    with the greatest degree of autonomy and self-choice, and include distraction, offering
    alternatives, verbal de-escalation and other such techniques taught in CPI training as well as
    other Behavioral Health Education classes. Most restrictive interventions include those
    interventions that provide the patient with the least autonomy and self-choice, and include the
    use of restraint or seclusion.
    Licensed Independent Practitioner (LIP): Defined by University of New Mexico Health
    Sciences Center (UNMHSC) Clinical Affairs as a practitioner permitted by New Mexico law
    and by the UNMHSC to provide patient care services without direction or supervision within
    the scope of the practitioner‟s license.
    Law enforcement restraint devices: Devices such as handcuffs, manacles, shackles, and
    other chain type restraint devices. The use of such devices by non-hospital employed or
    contracted law enforcement officers is governed by Federal and State laws and regulations
    and are not considered a health care intervention.
    Mechanical Restraint: Any device attached or adjacent to the patient‟s body (i.e., use of
    wrist, ankle and/or torso restraints) to restrict a patient‟s freedom of movement, physical
    activity or normal access to his/her body. This is a form of physical restraint.
    Mental Health or Developmental Disability Professional: A person who by training or
    experience is qualified to work with persons with mental disorders or developmental
    disabilities.
    Physical Restraint –The application of physical force without the use of a device, or the use
    of a mechanical device, material, or equipment attached or adjacent to the patient's body that
    immobilizes or restricts freedom of movement of or normal access to a patient's body. This
    includes Crisis Prevention Institute‟s (CPI) Children‟s Control Position (previously titled a
    „baskethold‟), as well as physical escorts used to restrict a patient‟s freedom of movement
    (i.e., the CPI Transport Hold).
     Physical restraint does NOT include the assistance with ambulation that a patient care
         attendant or other staff member may provide for a patient who is at risk of falls or who
         otherwise needs assistance with ambulation and transfers.
     Physical restraint does NOT include voluntary mechanical supports that allow for greater
         freedom of mobility or to achieve proper body position or balance (i.e., leg or neck
         braces).
     Physical restraint does NOT include medically necessary and voluntary positioning or
         securing devices used to maintain position, limit mobility or temporarily immobilize
         during a medical, dental or surgical procedure such as positioning straps used during
         surgery or intravenous arm boards used to stabilize an intravenous line.

_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 13 of 15
    Seclusion: The involuntary confinement of a patient alone in a room or an area from which
    the patient is physically prevented from leaving. Seclusion may only be used for the
    management of violent or self-destructive behavior. Seclusion is only used at the University
    of New Mexico Psychiatric Center and the University of New Mexico Children's Psychiatric
    Center. Patients in seclusion are continuously monitored.
    Serious injury: Any significant impairment of the physical condition of a patient as
    determined by qualified medical personnel. This includes but is not limited to burns,
    lacerations, bone fractures, substantial hematoma and injuries to internal organs, whether self
    inflicted or inflicted by someone else
    Time out: A procedure used to assist a patient regain emotional control by restriction for a
    period of time to a designated area from which the patient is not physically restricted from
    leaving. The patient is encouraged to be in a quiet area such as unlocked room. The cottage
    staff monitors the patient‟s well being during the time out. This monitoring includes
    checking in with the patient and intervening if the patient has needs that are not being met by
    a time out. If the patient‟s ability to leave the quiet area is restricted by staff, then the
    intervention is no longer a time out and is considered to be seclusion. Time outs may be
    requested by the patient or offered by milieu staff, including mental health technicians who
    have been trained in the use of de-escalation techniques. Time outs requested, offered and/or
    used must be fully documented in the progress notes. Time outs offered and taken are
    discussed by the treatment team and documented in the treatment plan update.

SUMMARY OF CHANGES
This policy revises the 2003 UNMHSC Use of Restraint and/or Seclusion for Behavioral
Reasons policy.

KEY WORDS: physical restraint, mechanical restraint, seclusion, chemical restraint, crisis
response team, critical incident, serious injury, time out


RESOURCES/TRAINING


                   Resource/Dept                                              Internet/Link
 Behavioral Health Education
 Clinical Education

DOCUMENT APPROVAL & TRACKING

            Item                                    Contact                            Date             Approval
 Owner                         Director, Behavioral Health Education and Nursing
                               Executive Director, Education and Research
 Consultant(s)
                               Executive Director, Quality Outcomes Management
                               Children‟s Psychiatric Center Aggression Reduction Task Force
 Committee(s)                  UNM Psychiatric Center Aggression Reduction Task Force                   [Y or N/A]
                               Behavioral Health Best Practices Committee
 Nursing Officer               [Name], Chief Nursing Officer                                            [Y or N/A]
 Medical Director/Officer      [Name, Department (or Chief Medical Officer)]                            [Y or N/A]
 Human Resources               [Name], HR Administrator, [UNMH or UNM]                                  [Y or N/A]

_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 14 of 15
 Finance                       [Name, Title], [UNMH or HSC]                                             [Y or N/A]
 Legal                         [Name, Title], [UNMH or HSC]                                             [Y or N/A]
 Official Approver             [Name, Title, Area]                                                          Y
 Official Signature                                                                 [Day/Mo/Year]
  nd
 2 Approver (Optional)
 Signature                                                                          [Day/Mo/Year]
 Effective Date                                                                     [Day/Mo/Year]
 Origination Date                                                                   [Month/Year]
 Issue Date                    Clinical Operations Policy Coordinator

ATTACHMENTS
UNM PC Restraint and seclusion flow sheet
UNM PC Individual Crisis Management Form
UNM CPC Individual Crisis Management Form
UNM CPC Restraint and seclusion flow sheet
UNM CPC Crisis Team Critique Form
Value Options Critical Incident Form
Department of Health/Division of Health Improvement Incident Reporting Form




_________________________________________________________________________________________________________________
Title: Use of restraint or seclusion for behavioral health reasons
Owner: Director of Behavioral Health Education and Nursing
Effective Date:
                                                Page 15 of 15

				
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