C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.09

Current through 2024-51, December 18, 2024

Subsection 144-101-II-107.09 - REQUIREMENTS FOR USE OF RESTRAINT AND SECLUSION

107.09-01 General Requirements

Restraint and Seclusion may be utilized by the provider and must be done in adherence with 42 C.F.R. part 483 Subpart G, the Maine Rights of Recipients of Mental Health Services, and the Rights of Recipients of Mental Health Services who are Children in Need of Treatment. Restraints or Seclusion. When there are conflicting provisions in these sources, the provision that provides the member the most protection applies. Restraint and seclusion may only be employed under the following circumstances:

A. When the intervention is absolutely necessary to protect the member from causing serious physical harm to self or others. Restraint or seclusion must not be utilized solely to address the comfort, convenience, or anxiety of staff, or as a form of coercion, discipline, or retaliation;

B. The intervention is the least restrictive emergency safety intervention necessary to resolve the emergency safety situation after other methods have been proven ineffective or inappropriate;

C. The restraint or seclusion is performed only by staff with specific training in these interventions. These interventions are applied in a manner that is safe, proportionate, and appropriate to the severity of behavior, and the member's chronological and developmental age, size, gender, physical conditions, psychiatric conditions, medical conditions, and personal history. The restraint or seclusion must not result in harm or injury to the member and must be used only:

1. To ensure the safety of the member or others during an emergency safety situation; and

2. Until the emergency situation has ceased and the member's safety and the safety of others can be ensured, even if the restraint or seclusion order has not expired; and

D. Restraint (including physical and mechanical restraints) and seclusion must not be used simultaneously; and

E. Locked seclusion is prohibited. The member may not be confined alone to any area with the door locked, barred, or held shut by staff.

F. For minor members, the Treatment Planning Team must decide and document in the Treatment Plan whether to allow restraints to be employed on a particular member in the event of an emergency safety situation and where the requirements of this section are met

107.09-02Orders for Restraint or Seclusion

A. The restraint or seclusion must be ordered by a physician or a nurse practitioner who is acting under the guidance of the team physician. When the team physician is available, only he or she may order restraint or seclusion. In the event that the provider ordering restraint or seclusion is not the treatment planning team physician, the ordering provider must consult with the member's treatment planning team physician as soon as possible and inform him or her of the emergency safety situation that required the member to be restrained or placed in seclusion and document in the member's record the date and time the team physician was consulted. The order must be the least restrictive emergency safety intervention that is most likely to be effective in resolving the emergency safety situation based on consultation with staff.

B. An order for restraint or seclusion may be given after an examination by a physician or nurse practitioner. In the event neither are available, a registered nurse, acting in consultation with and in accordance with protocol approved by the Medical Director, may conduct the examination and approve the emergency safety intervention.

C. An order for restraint or seclusion must not be written as a standing order or on an as-needed (PRN) basis. An order for restraint or seclusion may be given only during or immediately after the emergency safety situation arises.

D. The order must include:

1. The name of the ordering physician, or nurse practitioner permitted to order restraint or seclusion;

2. The date and time the order was obtained;

3. The reason for the restraint or seclusion;

4. The emergency safety intervention ordered, including the authorized length of time for the intervention and the conditions under which the member may be sooner released; and

E. Each order for restraint or seclusion must adhere to the following:

1. Be limited to no longer than the duration of the emergency safety situation;

2. Under no circumstances exceed four (4) hours for members ages 18-21; two (2) hours for members ages 9-17; or one (1) hour for members up to age 9; and

3. The order must be signed by the ordering physician, or nurse practitioner in the member's record as soon as possible.

F. If the order for restraint or seclusion is verbal, the verbal order must be received by a registered nurse, while the emergency safety intervention is being initiated by staff, or immediately after the emergency safety situation ends. The physician or other licensed practitioner permitted to order restraint or seclusion must verify the verbal order in a signed written form in the member's record. The physician or other licensed practitioner permitted to order restraint or seclusion must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention;

G. Under no circumstances may prone restraints be ordered or used. Additionally, providers must not initiate or sustain any restraint that may hinder chest and abdomen movement.

107.09-03Monitoring of the Member

A. Monitoring of the Member During and Immediately Following Restraint

1. Clinical staff trained in the use of restraints must be physically present, continually assessing and monitoring the physical and psychological well-being of the member and the safe use of restraint throughout the duration of the emergency safety intervention.

2. Every member placed in restraint shall be released as necessary to eat, drink, bathe, toilet and to meet any special medical orders. Members in restraint shall have each extremity examined and the restraint loosened, sequentially, no less frequently than every fifteen (15) minutes. In instances in which blanket wraps are utilized for restraint, the member will be released and examined no less frequently than every hour.

3. A special progress/check sheet shall be maintained for each use of restraint. In addition to documenting the requirements of this provision, a description of the member's behavior as observed shall be noted on the special progress/check sheet every fifteen (15) minutes.

4. If the emergency safety situation continues beyond the time limit of the order for the use of restraint, a registered nurse must immediately speak with the ordering physician or nurse practitioner permitted to order restraint or seclusion to receive further instructions.

5. A physician, nurse practitioner, RN or LPN trained in the use of emergency safety interventions must evaluate the member's well-being immediately after the restraint is removed.

B. Monitoring of the Member During and Immediately After Seclusion

1. Clinical staff trained in the use of seclusion must be physically present in or immediately outside the seclusion room, continually assessing, monitoring, and evaluating the physical and psychological well-being of the member in seclusion. Video monitoring does not meet this requirement.

2. Every member placed in seclusion shall be released, unless clinically contraindicated, at least every two (2) hours to eat, drink, bathe, toilet and to meet any special medical orders.

3. A special progress/check sheet shall be maintained for each use of seclusion. In addition to documenting the requirements of 107-09.03.B.2 above, a description of the member's behavior as observed shall be noted on the special progress/check sheet every fifteen (15) minutes

4. A room used for seclusion must:

a. Allow staff full view of the member in all areas of the room; and

b. Be free of potentially hazardous materials, objects, or conditions such as unprotected light fixtures, phone cords, and electrical outlets.

5. If the emergency safety situation continues beyond the time limit of the order for the use of seclusion, a registered nurse must immediately speak with the ordering physician or nurse practitioner permitted to order restraint or seclusion to receive further instructions; and

6. A physician, nurse practitioner, RN, or LPN trained in the use of emergency safety interventions must evaluate the member's well-being immediately after member is removed from seclusion.

107.09-04Examination Following Use of Restraint or Seclusion

A. Within thirty (30) minutes of the initiation of the emergency safety intervention, the team physician, or nurse practitioner must conduct a face-to-face of the physical and psychological well-being of the member. If the examination is not able to occur within thirty (30) minutes, the reason why must be documented in the member's record. The examination may be in person, or by phone in consult with a registered nurse. Documentation of the physician's or nurse practitioner's examination must be entered into the member's record. When a telephonic consult occurs, the physician, or nurse practitioner must examine the member in person within the following time constraints:

1. Within one (1) hour of when the registered nurse requests an examination;

2. Within one (1) hour of when information relayed is suggestive of causes leading to physical harm to the member;

3. Within one (1) hour if an examination has not yet occurred during the member's stay; or

4. Within six (6) hours in all other circumstances.

B. Thereafter, the need for a member's continuation in the emergency safety intervention shall be re-evaluated every two hours by a nurse. The nurse shall examine the member in person. For a member subject to an order of seclusion, the examination may be conducted outside the seclusion area; the nurse shall note the clinical reasons for selection of the examination site. For a member subject to an order of restraint, the examination may be conducted with the member free of restraints; the nurse shall note the clinical reasons for selecting whether the member is examined in or free or restraints. The nurse shall assess the member to determine whether the intervention is absolutely necessary to protect the member from causing serious harm to self or others. If the nurse finds these conditions are still met, then the emergency safety intervention may be continued if the physician's or nurse practitioner's order has not yet lapsed. Should the member not need continued seclusion or restraint, the nurse shall release the member even if the time frame of the original order has not yet lapsed. Documentation of the nurse's examination must be entered into the member's record.

C. In addition to the above criteria, examinations conducted under this section include, but are not limited to:

1. The member's physical and psychological status, including vital signs;

2. The member's behavior;

3. The appropriateness of the intervention measures; and

4. Any complications resulting from the intervention.

107.09-05Use of Time Outs

A. A member in time out must never be physically prevented from leaving the time out area;

B. Time out may take place away from an activity or from other members, such as in the member's room (exclusionary), or in the area of activity of other members (inclusionary);

C. Staff must monitor the member while he or she is in time out.

107.09-06Documentation of Restraint and Seclusion

A. Documentation regarding the use of restraint and seclusion must be kept within the member record; and must be completed by the end of the shift in which the intervention occurs. If the intervention does not end during the shift in which it began, documentation must be completed during the shift in which it ends. Documentation of the restraint or seclusion must include all the following:

1. Each order for restraint or seclusion as required in Section 107.09-02 above;

2. The time the emergency safety intervention actually began and ended;

3. The time and results of the examinations as required in Section 107.09-04 above;

4. The emergency safety situation that required the member to be restrained or put into seclusion;

5. The name(s) of the staff involved in the emergency safety intervention;

6. The outcome of the situation; and

7. The member's vital signs.

B. If the member is a minor or has a legal guardian:

1. The facility must notify the parents or legal guardians of the member who has been restrained or placed in seclusion as soon as possible after the initiation of the restraint or seclusion. Families or guardians may not waive this requirement.

2. The facility must document in member's record that the parents or legal guardians have been notified of the emergency safety intervention, including the date and time of notification and the name of the staff providing the notification.

107.09-07Post-intervention Debriefings

A. Within 24 hours after the use of restraint or seclusion, staff involved in an emergency safety intervention and the member must have a face to face discussion. This discussion must include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the member. Other staff may participate in the discussion when it is deemed appropriate by the facility. The member's parents or legal guardians, as applicable, must be given the opportunity to participate in the discussion, unless clinical staff have determined that participation would be detrimental to the member. The facility must conduct such discussion in a language that is understood by the member's parents or legal guardians. The discussion must provide both the member and the staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the member, or others that could prevent the future use of restraint or seclusion.

B. Within 24 hours after the use of restraint or seclusion, all staff involved (including any clinical staff involved) in the emergency safety intervention, and appropriate supervisory and administrative staff, must conduct a separate debriefing session (to not include the member) that includes, at a minimum, a review and discussion of:

1. The emergency situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention; and

2. Alternative techniques that might have prevented the use of restraint or seclusion; and

3. The procedures, if any, that staff are to implement to prevent any recurrence of the use of restraint or seclusion; and

4. The outcome of the intervention, including any injuries that may have resulted from the use of restraint or seclusion.

C. Staff must document in the member's record that both debriefing sessions took place and must include in that documentation the names and signatures of staff who were present for the debriefing, the names of staff that were excused from the debriefing (and the reason for the non-presence of the staff), and any changes to the member's treatment plan that result from the debriefings.

107.09-08Medical Treatment for Injuries Resulting from an Emergency Safety Intervention

Members requiring Third Party Treatment of Medical and Psychological Conditions are subject to the following requirements:

A. Staff must immediately obtain medical treatment from qualified medical personnel for a member injured as a result of use of a restraint or seclusion.

B. The PRTF must have affiliations or written transfer agreements in effect with one or more hospitals enrolled with MaineCare that reasonably ensure that:

1. A member will be transferred from the facility to a hospital and admitted in a timely manner when a transfer is medically necessary for medical care or acute psychiatric care;

2. Medical and other information needed for care of the member in light of such a transfer will be exchanged between the institutions in accordance with state medical privacy law (including 22 M.R.S. §1711-C and 34-B M.R.S. §1207), including any information needed to determine whether the appropriate care can be provided in a less restrictive setting; and

3. Services are available to each member twenty-four hours a day, seven days a week.

C. Staff must document in the member's record all injuries that occur as a result of the use of restraints or seclusion, including injuries to staff resulting from the intervention.

D. Staff involved in the use of restraint or seclusion that results in injury to a member or staff must meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-107, subsec. 144-101-II-107.09