N.J. Admin. Code § 8:43G-18.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43G-18.4 - Nursing care; use of restraints

(a) The standards in this section shall apply to the use of physical restraints in all patient care areas of the hospital. Physical restraints are defined as devices, materials, or equipment that are attached or adjacent to a person and that prevent free bodily movement to a position of choice, with the exception of devices used for positioning supports necessary for medical treatment.

(b) The hospital shall have written policies and procedures regarding the use of physical restraints that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least the following:

1. Protocol for the use of alternatives to physical restraints, such as staff or environmental interventions, structured activities, or behavior management. Alternatives shall be utilized whenever possible to avoid the use of restraints;

2. Protocol for the use and documentation of a progressive range of restraining procedures from the least restrictive to the most restrictive;

3. A delineation of indications for use, which shall be limited to:

i. Prevention of imminent harm to the patient or other persons when other means of control are not effective or appropriate; or

ii. Prevention of serious disruption of treatment or significant damage to the physical environment;

4. Contraindications for use, including at least clinical contraindications, convenience of staff, or discipline of the patient;

5. Identification of restraints which may be used in the hospital, which shall be limited to methods and mechanical devices that are specifically manufactured for the purpose of physical restraint;

6. Protocols for notifying the family or guardian of reasons for use of restraints, and for informing the patient and requesting consent when clinically feasible; and

7. Protocol for removal of restraints when goals have been accomplished.

(c) Except in an emergency, a patient shall be physically restrained only after the attending physician or another designated physician has personally seen and evaluated the patient and has executed a written order for restraint.

(d) An emergency restraint procedure, beginning with the least restrictive alternative that is clinically feasible, shall be initiated by a registered professional nurse only when the safety of the patient or others is endangered or there is imminent risk that the patient will cause substantial property damage. The attending physician, another designated physician, a licensed physician assistant, or a nurse practitioner/clinical nurse specialist shall be notified immediately and shall respond within one hour. An order shall be given if the use of restraints is to continue beyond one hour. The clinical condition of the patient shall be evaluated and documented by medical or licensed nursing personnel at least once every two hours.

(e) In all cases, the attending or designated physician, licensed physician assistant, or advanced practice nurse shall observe the restrained patient at least once every 24 hours to evaluate any changes in the patient's clinical status. This evaluation shall be documented in the patient record. If a physician has ordered the use of restraints, a subsequent order for the use of restraints shall not be required so long as its use is in compliance with the intent of the original order and hospital policy.

(f) Interventions while a patient is restrained, except as indicated at (g) below, shall be performed by nursing personnel in accordance with nursing care policy. They shall include at least the following and shall be documented:

1. Assessment for clinical status and reevaluation of need for restraints at least every two hours;

2. Toileting at least every two hours with assistance if needed;

3. Monitoring of vital signs; and

4. Release of restraints at least once every two hours in order to:

i. Assess circulation and skin integrity;

ii. Perform skin care; and

iii. Provide an opportunity for exercise or perform range of motion procedures for a minimum of five minutes per limb.

5. Continuous or periodic visual observation based upon an evaluation of the patient's clinical condition.

6. Administration and monitoring of adequate fluid intake;

7. Adequate nutrition through meals at regular intervals, snacks, and assistance with feeding if needed;

8. Assistance with bathing as required, occurring at least once a day; and

9. Ambulation at least once every four hours if clinically feasible.

(g) Interventions for patients wearing vest or similar restraints for overnight sleeping shall be performed by nursing personnel in accordance with nursing care policy. They shall include at least the following and shall be documented:

1. Periodic visual observation based on patient acuity occurring at least once every hour;

2. Administration of fluids as required;

3. Toileting as required; and

4. Release of restraints at least once every two hours for repositioning and skin care, unless clinically contraindicated.

(h) Registered professional nursing staff shall evaluate and ensure appropriate monitoring and documentation of the effects of all psychotropic medications. These medications shall be administered only upon written physician orders as part of the patient's treatment plan and shall not be used as a method of restraint, discipline, or for the convenience of staff.

N.J. Admin. Code § 8:43G-18.4

New Rule, R.1992 d.72, effective 2/18/1992.
See: 23 New Jersey Register 2590(a), 24 New Jersey Register 590(a).
Amended by R.1999 d.436, effective 12/20/1999.
See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey Register 4293(c).
In (a), added an exception at the end; in (b), substituted "at least once every three years, revised more frequently as needed" for "annually, revised" in the introductory paragraph; and rewrote (d) through (f).