Meeting Regulatory Standards for the Use of Violent Restraint & Seclusion
DID YOU KNOW:
Restraint orders should NEVER be written as PRN orders. A NEW ORDER is required if restraints are released, and the patient’s behavior requires re-application. A “trial release” constitutes PRN use and is NOT allowed. You cannot discontinue and restart restraints under the same order. Temporary, directly supervised release for caring for the patient’s needs is NOT considered discontinuing restraints. all the difference.
Restraint refers to any means of immobilizing or limiting a patient's movement, including manual methods, chemical or physical devices, materials, or equipment. This can include medication to manage a patient's behavior or restrict movement.
It is important to note that the use of violent restraints is not always necessary or appropriate. There are alternative methods of managing patient behavior that are less harmful, such as de-escalation techniques and the use of medications. In addition, healthcare providers can work to create a safe and supportive environment for patients, which may reduce the need for restraints in the first place.
Each patient has the right to receive care in a safe setting. The safety of the patient, staff or others is the basis for initiating and discontinuing the use of restraints and seclusion. Restraint is a last resort and may only be used when less restrictive interventions are ineffective to protect patient, staff, or others from harm. Reason for restraint use and alternatives attempted or rationale for not using alternatives must be clearly documented in the medical record. The use of restraint must be discontinued as soon as possible based on patient assessment and reevaluation. Staff must assess and monitor the patient’s condition on an ongoing basis to ensure that the patient is released from restraint at the earliest possible time.
Management of Violent/Self-destructive Behavior
Hospital policy and state regulation determine the categories of licensed individual practitioner (LIP) that may order restraints and seclusion. The order for restraints or seclusion must be obtained before the initiation of the intervention. In an emergency, however, the restraint or seclusion application may occur simultaneously or before obtaining an order. Still, the order must be obtained within a few minutes of the initiation of the restraint or seclusion. Although State law may have more restrictive time limits, each order for restraint or seclusion used for the management of violent/self-destructive behavior has maximum time limits based on age and may only be renewed in accordance with the following limits for up to a total of 24 hours:
4 hours for adults 18 years of age or older
2 hours for children and adolescents 9 to 17 years of age
1 hour for children under 9 years of age
Restraints or seclusion should be discontinued at the earliest possible time, regardless of the length of time identified in the order. At the end of each timeframe, if it has been determined that restraints or seclusion to manage violent/self-destructive behavior need to continue, another order is required. PRN orders are not allowed, and each new episode of restraint or seclusion requires a new order. A LIP must see and assess the patient after 24 hours (or as specified by State law) before issuing a new order. If the LP who ordered the restraint or seclusion was not the patient’s attending physician, the attending physician must be notified as soon as possible, as defined by hospital policy.
Face-to-Face Evaluation
When restraints or seclusion is used to manage violent/self-destructive behavior, the patient must be seen in person within one hour after initiating the intervention by a LIP or registered nurse trained to conduct a face-to-face evaluation. A telephone call or the use of telemedicine is not permitted for this evaluation. The purpose of the face-to-face evaluation is to complete a comprehensive review of the patient’s condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient’s violent or self-destructive behavior. Suppose a patient’s violent or self-destructive behavior resolves, and the restraint or seclusion is discontinued before the practitioner arrives to perform the one-hour face-to-face evaluation. In that case, the practitioner is still required to evaluate the patient within one hour of the initiation of the intervention.
During the one-hour face-to-face evaluation, the following must be evaluated:
The patient’s immediate situation
The patient’s reaction to the intervention
The patient’s medical and behavioral condition to determine if other factors are contributing to the patient’s violent or self-destructive behavior
Review of systems
Behavioral assessment
Review of history, drugs, medications, recent lab results,
The need to continue or terminate the restraint or seclusion
If a specially trained nurse (RN) performs a face-to-face evaluation. In that case, they must immediately consult with the attending physician or other licensed practitioner responsible for the patient's care (as outlined by hospital policy) after completing the evaluation. This consultation should cover the results of the one-hour face-to-face, any necessary interventions or treatments, and whether to continue or discontinue the use of restraint or seclusion.
When the simultaneous use of restraint and seclusion is used, the patient must be continually (ongoing without interruption) monitored either face-to-face by a trained staff member or by using both surveillance video and audio equipment that is in close proximity to the patient.
RESTRAINT REQUIREMENTS
Initiation | Must be ordered by MD. MD is to be notified within minutes of the initiation of restraints and an order obtained.
Re-order | New order is needed every 4 hours for adults of 18 years of age. Each order is renewed based upon an RN assessment and the consultation with the physician. Restraints are never written on a PRN basis.
Initial face-to-face | A physician, other licensed independent practitioner or specially trained RN (behavioral health RN) responsible for the care of the patient must evaluate the patient in-person within 1 hour of initiation of the restraint, even if restraints have been discontinued. Face to Face evaluation should include: evaluation of patient’s immediate situation, patient’s reaction to intervention, patient’s medical condition (review of systems, history, drugs, lab), behavioral condition and the need to continue or terminate restraint.
Renewal face- to-face | A physician, other licensed independent practitioner or specially trained RN (behavioral health) responsible for the care of the patient must evaluate the patient in-person every 24 hours while adult is in restraints.
Monitoring/ Documentation | Frequency of assessment and monitoring should depend on variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen intervention, and other relevant factors. Document rationale for monitoring and assessment in care plan/electronic medical record.
Every 15 to 30 min: current mental status, behavioral response, comfort measures, type of restraint, signs of injury if any, and continuous observation.
At Least Every 2 hrs.: Vital signs, peripheral neuro-vascular, hydration, nutrition, elimination, skin integrity. Restraints are removed one limb at a time for at least fifteen minutes, unless medically or psychiatrically contraindicated; range of motion/exercise, and body repositioning.
Education | Document patient/family education regarding restraints.
Care Plans | Care Plans should include restraint use & modify when restraints are discontinued or reapplied. Update each shift.
The most common restraint-related survey findings are face-to-face evaluations not completed with all required elements within 1 hour of initiation of violent/self-destructive restraints and failure to monitor patients per hospital policy. Immediate jeopardy (immediate threat/harm to patient) can be cited if indications for restraint use do not reflect the need for restraint or failure to monitor the patient as required per hospital policy, or the patient's condition puts the patient at risk of harm.