P.R. Laws tit. 24, § 6155c
Restraints shall be employed only at hospitals and centers with acute care wards or emergency rooms, and the same is to be employed abiding by the protocols of standards in the good practice of mental healthcare and pursuant to the provisions of this chapter. Restraints shall be used for therapeutic purposes, without infringing upon human dignity. Application thereof shall be reserved as an extreme resort, to be used when the adult is in immediate danger of inflicting harm upon him/herself or others or damaging property. Before restraining any adult, his/her physical condition shall be taken into account; Provided, That under no circumstance shall restraints be used as punishment, as a disciplinary measure, or for the convenience of the personnel of the institution.
Any mental healthcare professional qualified to order, administer and observe restraints shall complete training on the use and application of this therapeutic procedure in adults. The provisions of this section are subject to the regulations that the Administration shall promulgate for these purposes. Restraints shall be applied when there is a written order issued by a psychiatrist to that effect, who after having observed the adult, is clinically convinced that restraints are necessary. The examination shall include an evaluation of the physical condition and the mental state of the adult. It is required to enter the restraint order in the clinical record, which shall also include specific data, observations, purposes for its use, time used, and any other pertinent evidence that supports its employment.
The closest family member or legal guardian, as the case may be, shall be notified as soon as practicable, of the kind of restraints used. It shall be mandatory to conduct a review of the use of restraints as soon as practicable. The medical faculty and the medical director shall keep minutes of said review stating the reasons that support the use of this measure, in order to establish the medical-professional accountability of team members.
No restraint order shall be valid for more than twelve (12) hours after its issue. Restraints applied by virtue of said order shall not exceed more than four (4) hours, after which the psychiatrist shall conduct a new evaluation. If the results of the evaluations show that continuation of the use of restraints is necessary, the psychiatrist shall issue a new order, which shall be entered in the clinical record.
In case of emergencies that require the immediate use of this measure, when the psychiatrist is not available, restraints may be temporarily instituted by a physician or registered nurse, or a member of the inter- or multidisciplinary team duly trained and certified on this modality, who after consulting a psychiatrist by phone and having personally observed the patient, is clinically convinced that the use of restraints is indicated in order to keep the adult from inflicting harm upon him or herself or others or from damaging property. Once the psychiatrist is available, he/she shall conduct an evaluation to enter the written order in the clinical record as soon as practicable, but by no means shall it be after four (4) hours of the initial use of the emergency restraints. The need for a restraint order shall be entered in the clinical record. If after locating the psychiatrist, he/she does not authorize the use of restraints to continue, the use of restraints shall be immediately ceased. The psychiatrist who orders the use of restraints shall immediately notify so in writing to the medical director and the inter- or multidisciplinary team. A registered nurse trained and certified on this modality shall be assigned to observe the adult, at least every fifteen (15) minutes, without infringing upon the patient’s right to privacy, and enter his/her observations in the clinical record in a legible, clear, and precise manner.
Restraint orders of up to four (4) hours may be employed during all or part of a twelve (12)-hour period. Said period shall be counted as of the moment the restraint order was issued. Once employed, it shall be ceased as soon as it is clinically unnecessary. Restraints shall be removed every two (2) hours for not less than fifteen (15) minutes, unless said removal is clinically contraindicated.
Once restraints are used over a twelve (12)-hour period, these shall not be used again on the same adult for the next two (2) calendar days, unless there is an order justified by a psychiatric re-evaluation and the prior authorization from the medical director of the hospital institution.
The medical director shall review all restraint orders on a daily basis and investigate the reasons recorded for the same. Furthermore, he/she shall keep a register of the restraints used and render a yearly report to the Administration.
The institution shall establish in writing a protocol for the use of therapeutic restraints according to the provisions contained in this section. Said document shall include information about the mental healthcare professionals who are qualified to begin the use of restraints in case of an emergency, pursuant to the provisions of this chapter. Any healthcare professional qualified to begin, order, and observe the use of restraints must have completed a training course and be certified in the use and application of this therapeutic procedure. The provisions of this section shall be subject to the regulations and licensing requirements for institutional providers of mental healthcare services that the Administration shall promulgate for these purposes.
History —Oct. 2, 2000, No. 408, § 4.04; Aug. 6, 2008, No. 183, § 25.