Ariz. Admin. Code § 9-10-316

Current through Register Vol. 30, No. 16, April 19, 2024

Section R9-10-316 - Seclusion; Restraint

A. An administrator shall ensure that restraint is provided according to the requirements in subsection (C).

B. An administrator of a behavioral health inpatient facility authorized to provide seclusion shall ensure that:

1. Seclusion is provided according to the requirements in subsection (C);

2. If a patient is placed in seclusion, the room used for seclusion:

a. Is approved for use as a seclusion room by the Department;

b. Is not used as a patient's bedroom or a sleeping area;

c. Allows full view of the patient in all areas of the room;

d. Is free of hazards, such as unprotected light fixtures or electrical outlets;

e. Contains at least 60 square feet of floor space; and

f. Except as provided in subsection (B)(3), contains a non-adjustable bed that:

i. Consists of a mattress on a solid platform that is:

(1) Constructed of a durable, non-hazardous material; and

(2) Raised off of the floor;

ii. Does not have wire springs or a storage drawer; and

iii. Is securely anchored in place;

3. If a room used for seclusion does not contain a non-adjustable bed required in subsection (B)(2)(f):

a. A piece of equipment is available that:

i. Is commercially manufactured to safely and humanely restrain a patient's body;

ii. Provides support to the trunk and head of a patient's body;

iii. Provides restraint to the trunk of a patient's body;

iv. Is able to restrict movement of a patient's arms, legs, body, and head;

v. Allows a patient's body to recline; and

vi. Does not inflict harm on a patient's body; and

b. Documentation of the manufacturer's specifications for the piece of equipment in subsection (B)(3)(a) is maintained; and

4. A seclusion room may be used for services or activities other than seclusion if:

a. A sign stating the service or activity scheduled or being provided in the room is conspicuously posted outside the room;

b. No permanent equipment other than the bed required in subsection (B)(2)(f) is in the room;

c. Policies and procedures:

i. Delineate which services or activities other than seclusion may be provided in the room,

ii. List what types of equipment or supplies may be placed in the room for the delineated services, and

iii. Provide for the prompt removal of equipment and supplies from the room before the room is used for seclusion; and

d. The sign required in subsection (B)(4)(a) and equipment and supplies in the room, other than the bed required in subsection (B)(2)(f), are removed before being used for seclusion.

C. An administrator shall ensure that:

1. Policies and procedures for providing restraint or seclusion are established, documented, and implemented to protect the health and safety of a patient that:

a. Establish the process for patient assessment, including identification of a patient's medical conditions and criteria for the on-going monitoring of any identified medical condition;

b. Identify each type of restraint or seclusion used and include for each type of restraint or seclusion used:

i. The qualifications of a personnel member who can:

(1) Order the restraint or seclusion,

(2) Place a patient in the restraint or seclusion,

(3) Monitor a patient in the restraint or seclusion,

(4) Evaluate a patient's physical and psychological well-being after being placed in the restraint or seclusion and when released from the restraint or seclusion, or

(5) Renew the order for restraint or seclusion;

ii. On-going training requirements for a personnel member who has direct patient contact while the patient is in a restraint or seclusion; and

iii. Criteria for monitoring and assessing a patient including:

(1) Frequencies of monitoring and assessment based on a patient's medical condition and risks associated with the specific restraint or seclusion;

(2) For the renewal of an order for restraint or seclusion, whether an assessment is required before the order is renewed and, if an assessment is required, who may conduct the assessment;

(3) Assessment content, which may include, depending on a patient's condition, the patient's vital signs, respiration, circulation, hydration needs, elimination needs, level of distress and agitation, mental status, cognitive functioning, neurological functioning, and skin integrity;

(4) If a mechanical restraint is used, how often the mechanical restraint is loosened; and

(5) A process for meeting a patient's nutritional needs and elimination needs;

c. Establish the criteria and procedures for renewing an order for restraint or seclusion;

d. Establish procedures for internal review of the use of restraint or seclusion; and

e. Establish medical record and personnel record documentation requirements for restraint and seclusion, if applicable;

2. An order for restraint or seclusion is:

a. Obtained from a physician or registered nurse practitioner, and

b. Not written as a standing order or on an as-needed basis;

3. Restraint or seclusion is:

a. Not used as a means of coercion, discipline, convenience, or retaliation;

b. Only used when all of the following conditions are met:

i. Except as provided in subsection (C)(4), after obtaining an order for the restraint or seclusion;

ii. For the management of a patient's aggressive, violent, or self-destructive behavior;

iii. When less restrictive interventions have been determined to be ineffective; and

iv. To ensure the immediate physical safety of the patient, to prevent imminent harm to the patient or another individual, or to stop physical harm to another individual; and

c. Discontinued at the earliest possible time;

4. If as a result of a patient's aggressive, violent, or self-destructive behavior, harm to the patient or another individual is imminent or the patient or another individual is being physically harmed, a personnel member:

a. May initiate an emergency application of restraint or seclusion for the patient before obtaining an order for the restraint or seclusion, and

b. Obtains an order for the restraint or seclusion of the patient during the emergency application of the restraint or seclusion;

5. An order for restraint or seclusion includes:

a. The name of the physician or registered nurse practitioner ordering the restraint or seclusion;

b. The date and time that the restraint or seclusion was ordered;

c. The specific restraint or seclusion ordered;

d. If a drug is ordered as a chemical restraint, the drug's name, strength, dosage, and route of administration;

e. The specific criteria for release from restraint or seclusion without an additional order; and

f. The maximum duration authorized for the restraint or seclusion;

6. An order for restraint or seclusion is limited to the duration of the emergency situation and does not exceed three continuous hours;

7. If an order for restraint or seclusion of a patient is not provided by the patient's attending physician, the patient's attending physician is notified as soon as possible;

8. A medical practitioner or personnel member does not participate in restraint or seclusion, assess or monitor a patient during restraint or seclusion, or evaluate a patient after restraint or seclusion, and a physician or registered nurse practitioner does not order restraint or seclusion, until the medical practitioner or personnel member, completes education and training that:

a. Includes:

i. Techniques to identify medical practitioner, personnel member, and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion;

ii. The use of nonphysical intervention skills, such as de-escalation, mediation, conflict resolution, active listening, and verbal and observational methods;

iii. Techniques for identifying the least restrictive intervention based on an assessment of the patient's medical or behavioral health condition;

iv. The safe use of restraint and the safe use of seclusion, including training in how to recognize and respond to signs of physical and psychological distress in a patient who is restrained or secluded;

v. Clinical identification of specific behavioral changes that indicate that the restraint or seclusion is no longer necessary;

vi. Monitoring and assessing a patient while the patient is in restraint or seclusion according to policies and procedures; and

vii. Except for the medical practitioner, training exercises in which the personnel member successfully demonstrates the techniques that the medical practitioner or personnel member has learned for managing emergency situations; and

b. Is provided by individuals qualified according to policies and procedures;

9. When a patient is placed in restraint or seclusion:

a. The restraint or seclusion is conducted according to policies and procedures;

b. The restraint or seclusion is proportionate and appropriate to the severity of the patient's behavior and the patient's:

i. Chronological and developmental age;

ii. Size;

iii. Gender;

iv. Physical condition;

v. Medical condition;

vi. Psychiatric condition; and

vii. Personal history, including any history of physical or sexual abuse;

c. The physician or registered nurse practitioner who ordered the restraint or seclusion is available for consultation throughout the duration of the restraint or seclusion;

d. The patient is monitored and assessed according to policies and procedures;

e. A physician or registered nurse assesses the patient within one hour after the patient is placed in the restraint or seclusion and determines:

i. The patient's current behavior,

ii. The patient's reaction to the restraint or seclusion used,

iii. The patient's medical and behavioral condition, and

iv. Whether to continue or terminate the restraint or seclusion;

f. The patient is given the opportunity:

i. To eat during mealtime, and

ii. To use the toilet; and

g. The restraint or seclusion is discontinued at the earliest possible time, regardless of the length of time identified in the order;

10. A medical practitioner or personnel member documents the following information in a patient's medical record before the end of the shift in which the patient is placed in restraint or seclusion or, if the patient's restraint or seclusion does not end during the shift in which it began, during the shift in which the patient's restraint or seclusion ends:

a. The emergency situation that required the patient to be restrained or put in seclusion;

b. The times the patient's restraint or seclusion actually began and ended;

c. The time of the assessment required in subsection (C)(9)(e);

d. The monitoring required in subsection (C)(9)(d);

e. The names of the medical practitioners and personnel members with direct patient contact while the patient was in the restraint or seclusion;

f. The times the patient was given the opportunity to eat or use the toilet according to subsection (C)(9)(f); and

g. The patient evaluation required in subsection (C)(12);

11. If an emergency situation continues beyond the time limit of an order for restraint or seclusion, the order is renewed according to policies and procedures that include:

a. The specific criteria for release from restraint or seclusion without an additional order, and

b. The maximum duration authorized for the restraint or seclusion; and

12. A patient is evaluated after restraint or seclusion is no longer being used for the patient.

Ariz. Admin. Code § R9-10-316

Section R9-10-316, formerly numbered as R9-10-216, renumbered as an emergency effective February 22, 1979, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 79-1). Adopted effective June 14, 1979 (Supp. 79-3). Former Section R9-10-316 repealed, new Section R9-10-316 adopted effective February 4, 1981 (Supp. 81-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-316 made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019.