6 Colo. Code Regs. § 1011-1 Chapter 02, pt. 8

Current through Register Vol. 47, No. 20, October 25, 2024

Part 8 - PROTECTION OF CLIENTS FROM INVOLUNTARY RESTRAINT OR SECLUSION

8.1Statutory Authority and Applicability.

8.1.1 The statutory authority for the promulgation of these rules is set forth pursuant to section 26-20-101, et. seq., C.R.S.

8.1.2 This Part applies to the use of involuntary restraint and seclusion in all licensed health care facilities, except for:

(A) Hospitals as provided for in Part 8.2.1(A)(1); and

(B) Medicare/Medicaid certified nursing homes as provided for in Part 8.2.1(A)(2).

8.1.3 In accordance with section 26-20-102(b)(I), C.R.S., this Part 8 does not apply to facilities or agencies within the Department of Corrections or a public or private entity that has entered into a contract for services with such department.

8.2Exemptions

8.2.1 "Restraint" does not include:

(A) The use of any form of restraint in a licensed or certified hospital when such use:

(1) Is in the context of providing medical or dental services that are provided with the consent of the client or the client's guardian. For the purposes of this Part (A)(1) the term "medical services" means the voluntary provision of care in a hospital where the primary goal of treatment is treatment of a medical condition as opposed to treatment of a psychiatric disorder, and

(2) Is in compliance with industry standards adopted by a nationally recognized accrediting body or the conditions of participation adopted for federal Medicare and Medicaid programs.

(B) Methods typically used for medical-surgical care, such as the use of bandages and orthopedically prescribed devices, the use of a required device to limit mobility during a medical procedure, or the use of a drug when it is part of a standard treatment or dosage for the patient's condition.

(C) The use of protective devices or adaptive devices for providing physical support, prevention of injury, or voluntary or life-saving medical procedures.

(D) The holding of an individual for less than five (5) minutes by a staff person for protection of the individual or other persons.

(E) Placement of a client in their room for the night in an inpatient or residential setting.

8.2.2 This Part 8 does not apply to a facility or agency engaged in transporting a person from one facility, agency, or location to another facility, agency, or location when it is within the scope of that facility's or agency's powers and authority to effect such transportation.

8.2.3 A facility, as defined in section 27-65-102(7), C.R.S., that is designated by the Executive Director of the Department of Human Services to provide treatment pursuant to sections 27-65-105 through 27-65-107, C.R.S., to any person with a mental illness, as defined in section 27-65-102(14), C.R.S., may use seclusion to restrain a person with a mental illness when the seclusion is necessary to eliminate a continuous and serious disruption of the treatment environment.

8.2.4 If the use of restraint in skilled nursing and nursing care facilities licensed under state law is in accordance with the federal statutes and regulations governing the Medicare program set forth in 42 U.S.C. sec. 1395i-3(c) and 42 C.F.R. part 483, subpart B and the Medicaid program set forth in 42 U.S.C. sec. 1396r(c) and 42 C.F.R. part 483, subpart B and with 6 CCR 1011-1, Chapter 5, Nursing Care Facilities, there shall be a conclusive presumption that such use of restraint is in accordance with this Part 8.

8.2.5 If any provision of this Part 8 conflicts with any provision concerning the use of restraint or seclusion on an individual with an intellectual or developmental disability as stated in Article 10.5 of Title 27, C.R.S., Article 10 of Title 25.5, C.R.S. or any rule adopted pursuant to those articles, the provisions of those articles or rules shall prevail.

8.2.6 If any provision of this Part 8 concerning the use of restraint conflicts with any provision concerning the use of restraint stated in Article 65 of Title 27, C.R.S., or any regulation adopted pursuant thereto, the provision of Article 65 of Title 27, C.R.S., or the regulation adopted pursuant thereto shall prevail.

8.3Basis for Use of Restraint or Seclusion

8.3.1 A facility may only use restraint or seclusion:

(A) In cases of emergency, as defined at section 26-20-102(3), C.R.S., to be a serious, probable, imminent threat of bodily harm to self or others where there is the present ability to effect such bodily harm; and

(1) After the failure of less restrictive alternatives; or

(2) After a determination that such alternatives would be inappropriate or ineffective under the circumstances.

(B) A facility or agency that uses restraint or seclusion pursuant to the provisions of (A), above, shall use such restraint or seclusion:

(1) Only for the purpose of preventing the continuation or renewal of an emergency;

(2) Only for the period of time necessary to accomplish its purpose; and

(3) In the case of physical restraint, using no more force than is necessary to limit the client's freedom of movement.

8.3.2 Restraint and seclusion must never be used:

(A) As a punishment or disciplinary sanction,

(B) As a means of coercion by staff,

(C) As part of an involuntary treatment plan or behavior modification plan,

(D) For the convenience of staff,

(E) For the purpose of retaliation by staff, or

(F) For the purpose of protection, unless:

(1) The restraint or seclusion is ordered by the court, or

(2) In an emergency, as provided for in 8.3.1(A), above.

8.4Duties Relating to Use of Restraint or Seclusion

8.4.1 A facility or agency that uses restraint shall ensure that:

(A) At least every fifteen (15) minutes, staff shall monitor any client held in mechanical restraints to assure that the client is properly positioned, that the client's blood circulation is not restricted, that the client's airway is not obstructed, and that the client's other physical needs are met;

(B) No physical or mechanical restraint of a client shall place excess pressure on the chest or back of that client or inhibit or impede the client's ability to breathe;

(C) During physical restraint of a client, an agent or employee of the facility or agency shall check to ensure that the breathing of the client in such physical restraint is not compromised;

(D) A chemical restraint shall be given only on the order of a physician who has determined, either while present during the course of the emergency justifying the use of the chemical restraint or after telephone consultation with a registered nurse, certified physician assistant, or other authorized staff person who is present at the time and site of the emergency and who has participated in the evaluation of the client, that such form of restraint is the least restrictive, most appropriate alternative available;

(E) An order for a chemical restraint, along with the reasons for its issuance, shall be recorded in writing at the time of its issuance;

(F) An order for a chemical restraint shall be signed at the time of its issuance by such physician, if present at the time of the emergency;

(G) An order for a chemical restraint, if authorized by telephone, shall be transcribed and signed at the time of its issuance by an individual with the authority to accept telephone medication orders who is present at the time of the emergency; and

(H) Staff trained in the administration of medication shall make notations in the record of the client as to the effect of the chemical restraint and the client's response to the chemical restraint.

8.4.2 For clients in mechanical restraints, staff shall provide relief periods, except when the client is sleeping, of at least ten (10) minutes as often as every two (2) hours, so long as relief from the mechanical restraint is determined to be safe. During such relief periods, the staff shall ensure proper positioning of the client and provide movement of limbs, as necessary. In addition, during such relief periods, staff shall provide assistance for use of appropriate toileting methods, as necessary. The client's dignity and safety shall be maintained during relief periods. Staff shall note in the record of the individual being restrained the relief periods granted.

8.4.3 Relief periods from seclusion shall be provided for reasonable access to toilet facilities.

8.4.4 A client in physical restraint shall be released from such restraint within fifteen (15) minutes after the initiation of physical restraint, except when precluded for safety reasons.

8.5Staff Training Concerning the Use of Restraint and Seclusion

8.5.1 All facilities and agencies shall ensure that all staff involved in utilizing restraint or seclusion are trained in the appropriate use of restraint and seclusion.

(A) All facilities and agencies shall ensure that staff are trained to explain, where possible, the use of restraint or seclusion to the client who is to be restrained or secluded and to the client's designated representative, if appropriate.

8.6Documentation Requirements Related to the Use of Restraint and Seclusion

8.6.1 Each facility shall ensure that an appropriate notation of the use of restraint or seclusion is documented in the record of the client who was restrained or secluded. Each facility shall document the following in the client record:

(A) Type of restraint and length of time in the restraint or seclusion;

(B) Identification of staff involved in the initiation and application of the restraint or seclusion;

(C) Care provided while in the restraint or seclusion, including monitoring conducted and relief periods granted; and

(D) The effect of the restraint or seclusion on the client.

8.7Review Process

8.7.1 Each facility or agency that Utilizes restraint or seclusion under this Part 8 shall ensure that a review process is established for the appropriate use of the restraint or seclusion.

8.8Facility or Agency Policies Regarding the Use of Restraint and Seclusion

8.8.1 A facility or agency that uses restraint or seclusion shall develop and implement policies and procedures consistent with the requirements of this Part 8.

(A) A facility's or agency's policies and procedures regarding the use of restraint and seclusion may be more stringent than this Part 8, but shall not be less stringent.

8.8.2 A facility or agency that does not use restraint or seclusion shall include a written statement in its policies and procedures to that effect.

6 CCR 1011-1 Chapter 02, pt. 8