P.R. Laws tit. 24, § 6159g
(a) Restraints shall be applied only at hospital institutions, live-in treatment institutions for minors, and centers that have emergency acute care wards, and be used as established in the protocols of standards of the best practices of mental healthcare and pursuant to the provisions of this chapter. Restraints shall be used in a therapeutic manner without infringing upon human dignity. Their application shall be reserved as an extreme recourse, to be used when the minor is in immediate danger of inflicting harm upon him/herself or others or damaging property. Before restraining any minor, his/her physical condition shall be taken into consideration; Provided, That under no circumstance shall restraints be used as punishment, as a disciplinary action, or for the convenience of the personnel of the institution. The examination shall include an evaluation of the physical condition and the mental state of the minor.
(b) Any mental healthcare professional qualified to order, administer or observe the use of restraints shall complete training in the use and application of this therapeutic procedure on minors, children and adolescents. The provisions of this section shall be subject to the regulations that the Administration shall promulgate for these purposes. If restraints should be necessary, their use may be temporarily instituted by a physician, a healthcare professional, or a member of the inter- or multidisciplinary team who has been duly trained and certified in such modality, after consulting a child and adolescent psychiatrist. Restraints shall be in order after having personally observed the minor and being clinically convinced that the employment of restraints is indicated to prevent the minor from inflicting harm upon him/herself or others or from damaging property.
(c) The need for a restraint order shall be entered in the clinical record of the minor and notice shall be given as soon as practicable to the closest family member or the legal guardian of the minor. Once the child and adolescent psychiatrist consulted is available, such psychiatrist shall conduct the evaluation to make a written entry of the order in the record as soon as practicable, within the hour following the institution of their use for minors who are ten (10) years of age or older, and within the half hour for minors between the ages of seven (7) and nine (9) years. If after contacting the child and adolescent psychiatrist, such psychiatrist does not authorize continuation of the use of restraints, such use of restraints shall be ceased immediately; Provided, That restraints may never be employed on children under the age of seven (7) years as a therapeutic measure. It shall be mandatory to hold a discussion as soon as practicable about the use of medication and to enter the restraint order in the clinical record, which order shall contain specific data, observations, purpose of use, time of use, and any other pertinent evidence supporting the employment thereof.
(d) No restraint order shall be valid for more than eight (8) hours after its issue. The restraints applied by virtue of said order shall not be extended beyond two (2) hours for minors who are ten (10) years of age or older, or beyond one (1) hour for minors between seven (7) and nine (9) years of age, after which the child and adolescent psychiatrist, or in default thereof, a general psychiatrist, after consultation with the former, shall conduct a new evaluation after having personally observed the minor. If the results of the evaluation show that continuation of the use of restraints is necessary, the child and adolescent psychiatrist, or in default thereof, a general psychiatrist, after consultation with the former, shall issue a new order, which shall be entered in the clinical record.
(e) In no case shall the initial period exceed two (2) hours for minors who are ten (10) years of age or older, or one (1) hour for minors between seven (7) and nine (9) years of age. In the event that the clinical condition that led to the use of restraints continues, the child and adolescent psychiatrist, in consultation with the inter- or multidisciplinary team, shall evaluate the minor and may provide for the use of other therapeutic modalities. Restraints shall be removed every half hour for not less than fifteen (15) minutes, unless said removal is clinically contraindicated, or entirely when it is no longer necessary to achieve the objectives that prompted this therapeutic measure.
(f) The mental healthcare professional, as authorized under this section, who institutes the use of restraints, shall require that a nurse practitioner trained and certified on this modality be assigned to observe the minor, at least every fifteen (15) minutes, without infringing upon the minor’s right to privacy, and enter his/her observations in the clinical record in a legible, detailed, clear and precise manner.
(g) The psychiatrist ordering the use of restraints shall immediately give written notice thereof to the medical director and the inter- or multidisciplinary team. The medical director and the medical faculty shall review all restraint orders and investigate the reasons recorded therefor in order to establish the professional accountability of team members. The director of the institution shall keep a register of the restraints employed and render a yearly report to the Administration. The minor’s closest family member or his/her guardian shall be notified of any restraint orders as soon as practicable.
(h) The institution shall establish in writing a protocol for the use of therapeutic restraints, pursuant to the provisions set forth in this section. Said document shall include information about the mental healthcare professionals who are qualified to institute the use of restraints in case of an emergency, pursuant to the provisions of this chapter. Any healthcare professional qualified to institute, order and observe the use of restraints, must have completed a training course and be certified in the employment and application of this therapeutic measure. The provisions of this section shall be subject to the regulations and the licensing requirements for institutional providers of mental healthcare that the Administration shall promulgate for these purposes.
History —Oct. 2, 2000, No. 408, § 8.08; Aug. 6, 2008, No. 183, § 42.