Cal. Code Regs. tit. 9 § 784.38

Current through Register 2024 Notice Reg. No. 25, June 21, 2024

Section 784.38 - Restraint and Seclusion-Documentation and Reporting Policies and Procedures

(a) Care provided to a client in restraint or seclusion shall be documented in the client record.

(1) The policies and procedures of the mental health rehabilitation center shall describe the manner in which this documentation shall be entered in the client record.

(2) Notations, check marks, and flow charts are allowable if the chart provides opportunity for narrative descriptions by staff, when appropriate, and when sufficient to provide all the necessary information.

(b) The documentation shall include, but not be limited to, all of the following:

(1) Clinical condition, circulation, condition of limbs, and attention to hydration, elimination, and nutrition needs.

(2) Behavioral assessments.

(3) Justification for continued use of restraint or seclusion, the types of behaviors that would facilitate release and evidence that this information was communicated to the client, along with his or her response, if any.

(4) Time placed in and time removed from restraint or seclusion.

(5) 15-minute observations and assessments.

(6) When face-to-face interaction does not occur, documentation of the reason why that interaction was inappropriate or unnecessary and what alternative means were used to determine the client was not in distress.

(c) Quarterly, any facility that uses restraint or seclusion shall report to the local mental health director or designee, who shall transmit copies to the Department, all of the following:

(1) The number of restraint or seclusion incidents, or both.

(2) The number of restraint or seclusion incidents according to age, sex, race and primary diagnosis.

(3) The client's age shall be classified as one of the following:

(A) Age 18 to 64 years, inclusive, and

(B) Age 65 and over.

(d) Facilities that use restraint or seclusion, or both, shall have written policies and procedures concerning their use. These policies shall include the standards and procedures for all of the following:

(1) Placement of a person in restraint or seclusion, including a list of less restrictive alternatives, the situations in which the use of restraint or seclusion is to be considered and the physician(s) and psychologist(s) who can order its use.

(2) Assessment and release, including guidelines for duration of use of specific behavioral criteria for release.

(3) Provision of nursing care and medical care, including the administration of medication.

(4) Procedures for advocate notification regarding any client restrained or secluded for more than eight (8) hours.

(5) Provision of staff training.

(e) Facilities that use restraint or seclusion shall implement an oversight process to ensure that all incidents of seclusion and restraint are reviewed and that any incidents or patterns of use which do not comply with the mental health rehabilitation center's policies and procedures or other clinical or legal standards are investigated. This oversight process shall ensure that appropriate policies and procedures are developed and implemented, including training of staff. Consumer input into the oversight process shall be incorporated.

Cal. Code Regs. Tit. 9, § 784.38

1. New section filed 8-21-95 as an emergency; operative 8-21-95 (Register 95, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-17-95 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-9-96 as an emergency; operative 2-9-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-8-96 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-10-96 as an emergency; operative 6-10-96 (Register 96, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-8-96 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 10-8-96 as an emergency; operative 10-8-96 (Register 96, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-5-97 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-8-96 order transmitted to OAL 2-5-97; disapproved by OAL and order of repeal as to 10-8-96 order filed on 3-21-97 (Register 97, No. 12).
6. New section filed 3-21-97 as an emergency; operative 3-21-97 (Register 97, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-21-97 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-21-97 order, including renumbering of former section 784.38 to new section 787.12, and renumbering and amendment of former section 784.29 to new section 784.38, transmitted to OAL 7-21-97 and filed 8-21-97 (Register 97, No. 34).

Note: Authority cited: Sections 5675 and 5768, Welfare and Institutions Code; Section 3 of Chapter 678 of the Statutes of 1994. Reference: Sections 5675 and 5768, Welfare and Institutions Code.