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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5122 Department of Mental Health - Administration and Director |
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Chapter5122-26. Policies and Procedures for the Operation of Mental Health Services Agencies |
5122-26-16.1. Mechanical restraint and seclusion
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(A) The purpose of this rule is to state the specific requirements applicable to mechanical restraint and seclusion.
(B) The requirements for the use of mechanical restraint or seclusion do not apply:
(1) To restraint use that is only associated with medical, dental, diagnostic, or surgical procedures and is based on standard practice for the procedure. Such standard practice may or may not be described in procedure or practice descriptions (e.g., the requirements do not apply to medical immobilization in the form of surgical positioning, iv arm boards, radiotherapy procedures, electroconvulsive therapy, etc.);
(2) When a device is used to meet the assessed needs of an individual who requires adaptive support (e.g., postural support, orthopedic appliances) or protective devices (e.g., helmets, tabletop chairs, bed rails, car seats). Such use is always based on the assessed needs of the individual. Periodic reassessment should assure that the restraint continues to meet an identified individual need;
(3) To forensic and corrections restrictions used for security purposes, i.e., for custody, detention, and public safety reasons, and when not involved in the provision of health care.
(C) Mechanical restraint or seclusion shall not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is possible. It shall be employed for the least amount of time necessary in order that the individual may resume his/her treatment as quickly as possible.
(D) Implementation of mechanical restraint or seclusion.
(1) Authorized staff may implement mechanical restraint or seclusion at the direction and in the presence of an individual with specific clinical privileges/authorization granted by the provider to authorize mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse.
(2) Upon any implementation of mechanical restraint or seclusion, an individual with specific clinical privileges or authorization granted by the provider shall:
(a) Perform an assessment and document it in the clinical record. This assessment shall include, at minimum:
(i) The reason for the utilization of mechanical restraint or seclusion;
(ii) All prior attempts to use less restrictive interventions;
(iii) Notation that any previously identified contraindication to the use of mechanical restraint or seclusion were considered and the rationale for continued implementation of mechanical restraint or seclusion despite the existence of such contraindications ; and
(iv) A review of all current medications.
(v) Documentation of the individual's history of traumatic experiences as a means to gain insight into origins and patterns of the individual's actions.
(b) Assess and document vital signs; and
(c) Explain to the individual the reason for mechanical restraint or seclusion, and the required behaviors of the individual which would indicate sufficient behavioral control so that mechanical restraint or seclusion can be discontinued.
(3) For adults in mechanical restraint, an assessment shall include health and related safety concerns including body positioning, comfort and circulation.
(E) Ordering mechanical restraint or seclusion.
(1) Orders shall be written only by an individual with specific clinical privileges or authorization granted by the provider to order mechanical restraint or seclusion, and who is a:
(a) Psychiatrist or other physician; or
(b) Physician's assistant, certified nurse practitioner or clinical nurse specialist authorized to order restraint or seclusion in accordance with his or her scope of practice and as permitted by applicable law or regulation.
(2) Orders may be written for a maximum of:
(a) Two hours for mechanical restraint or seclusion of adults eighteen years of age or older;
(b) One hour for seclusion of children and adolescents age nine through seventeen; or
(c) Thirty minutes for seclusion of children under age nine.
(3) Prn orders are prohibited, whether individual or as a part of a protocol.
(4) When indicated, a verbal order from an individual with specific clinical privileges or authorization granted by the provider to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist shall be obtained by a registered nurse upon implementation of mechanical restraint or seclusion, or within one hour. Such order shall be signed within twenty four hours by an individual with specific clinical privileges or authorization granted by the provider to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist.
(5) After the original order for mechanical restraint or seclusion expires, the individual shall receive a face-to-face reassessment, as described in subsection five of this paragraph. The reassessment shall be by performed by an individual with specific clinical privileges or authorization granted by the provider to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist, who shall write a new order if mechanical restraint or seclusion is to be continued. However, provider policy and the original order may permit a registered nurse to perform such reassessment and make a decision to continue the original order for an additional:
(a) Two hours for mechanical restraint or seclusion of adults eighteen years of age or older up to a maximum of twenty-four hours;
(b) One hour for seclusion of children and adolescents age nine through seventeen up to a maximum of twenty-four hours; or
(c) Thirty minutes for seclusion of children under age nine up to a maximum of twelve hours.
(6) Continuation of orders cannot under any circumstances exceed the maximums stated in this paragraph without a face-to-face reassessment and a new written order. The reassessment shall be performed and new order written by an individual with specific clinical privileges or authorization granted by the agency to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist.
Such assessment shall be documented in the clinical record. It shall address the need for continued mechanical restraint or seclusion. It shall include a mental status examination, physical assessment, gross neurological assessment, and an assessment of the individual's verbal statements, level of behavioral control, and responses to stimuli and treatment interventions, unless contra-indicated for clear treatment reasons which shall be documented in the clinical record.
(7) Mechanical restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.
(F) Continuous monitoring of persons in mechanical restraint or seclusion.
(1) While in mechanical restraint or seclusion, persons shall be continuously monitored, i.e., constant visual observation by staff in a manner most conducive to the situation or person's condition.
(2) Documentation of the condition of the person shall be made in the clinical record at routine intervals not to exceed fifteen minutes or more often if the person's condition so warrants. Such documentation shall address attention to vital signs, circulation, range of motion, nutrition, hydration, hygiene, toileting, the need for continued mechanical restraint or seclusion, and other needs as necessary, and the appropriate actions taken.
(3) Upon conclusion of the mechanical restraint or seclusion, the results of a check of injuries shall be conducted and documented.
The appropriate actions taken for any injuries noted shall also be documented.
(G) Seclusion room requirements.
(1) The type of room in which seclusion is employed shall ensure:
(a) Appropriate temperature control, ventilation and lighting;
(b) Safe wall and ceiling fixtures, with no sharp edges;
(c) The presence of an observation window and, if necessary, wall mirror(s) so that all areas of the room are observable by staff from outside of the room; and
(d) That any furniture present is removable or is securely fixed for safety reasons.
(H) Clinically appropriate reason for the inability to implement any portion of this rule shall be documented in the clinical record, and shall be addressed in any staff de-briefing of the episode and in the provider's performance improvement process.