Your rights in hospitals regarding restraint and seclusion

RIGHTS IN HOSPITALS REGARDING

RESTRAINT AND SECLUSION

Hospitals may use restraint and seclusion only in cases of emergency and in compliance with strict standards. Additional requirements, not included here, apply when restraining children.

I. WHAT IS RESTRAINT?

"Restraint" is physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limit freedom of movement. Hospital staff may use four types of restraint to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others.

• Physical restraint --

Holding a patient in a way that restricts his or her movement.

• Mechanical restraint --

Using a device, such as four-point or full-sheet restraint, to restrict a patient's movement (excludes devices prescribed for medical purposes).

• Chemical restraint --

Medicating a patient against the patient's will for the purpose of restraint rather than treatment.

• Seclusion --

Placing a patient alone in a room so that the patient cannot see or speak with patients or staff and so that the patient cannot leave or believes he or she cannot leave. In facilities licensed, operated, or contracted for by the state Department of Mental Health (DMH), a mechanically restrained patient cannot be secluded.

II. WHEN MAY RESTRAINT BE USED?

Restraint may only be used to prevent violence in an emergency. An emergency is the occurrence of or serious imminent threat of extreme violence or self-destructive behavior, "where there is the present ability to effect such harm." Restraint may not be used for treatment, punishment, behavior modification, staff convenience or on an "as needed" basis (PRN orders). Restraint must be the most appropriate alternative available. Restraint may only be used when less restrictive interventions have been determined to be ineffective.

III. WHO MAY ORDER RESTRAINT?

Mechanical restraint, physical restraint and seclusion require written orders by an authorized physician or other licensed independent practitioner permitted by the state and hospital to order a restraint. If the physician or other qualified practitioner is unavailable, a designated staff person may authorize restraint for no more than one hour. A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within one hour after the initiation of the intervention. These orders may be renewed only to prevent a continued or renewed emergency. Only an authorized physician may order chemical restraint, but he or she may issue the order over the telephone by speaking to a registered nurse or certified physician's assistant who has personally examined the patient. A physician may only order chemical restraint if the medication has been previously authorized in the patient's treatment plan. Furthermore, chemical restraint may only be administered if it is the least restrictive, most appropriate alternative available. The treating physician must be consulted as soon as possible, if he or she does not order the restraint.

IV. HOW LONG MAY RESTRAINT CONTINUE?

When an emergency no longer exists, the patient must be released. Thus, staff should release a patient who, upon examination, appears calm. The total time which a patient

may be restrained is limited.

• An initial restraint or seclusion order is valid for three hours.
• After three hours, a superintendent, authorized physician, registered nurse, or certified physicians assistant may continue restraint or seclusion if the emergency still exists.
• After six hours, an authorized physician must examine the patient and renew the order.
• The maximum amount of restraint or seclusion allowed is eight hours in any 24 hour period unless the superintendent or his or her designee so authorizes.

V. WHAT FURTHER PROTECTIONS EXIST FOR RESTRAINED PATIENTS?

A patient in a facility operated by DMH, contracted for by DMH, or licensed by DMH has additional rights:

• The patient must be fully clothed consistent with patient safety and dignity;
• The patient must have access to the bathroom;
• The patient should be continually assessed by staff to determine if the restraint or seclusion is still needed. These checks must be made at least once every 30 minutes;
• Any space or device used must provide appropriate and safe ventilation, heating and lighting;
• Once restrained or secluded, staff should help the patient calm down by using appropriate interventions; and
• Staff must determine if the patient has a history of abuse by gathering information during intake from the patient, the patient's record, and, when necessary, from other treating clinicians. If the patient has an abuse history, staff will use strategies to help reduce the patient's agitation so as to avoid the need for restraint. If restraint or seclusion is necessary, staff must determine which type will be the least traumatic for the patient and which gender of staff would be most appropriate to administer or monitor it.

Furthermore, a patient in a DMH-operated facility has these additional rights:

• To avoid restraint, staff should attempt to calm the patient through talking and other non-violent means;
• The attendant accompanying the patient to the bathroom should be of the same sex as the patient;
• A patient may not be held in restraint or seclusion for more than one-half hour

without a break unless he or she poses a violent threat to self or others (or is asleep);

• A patient who is quiet must be released for a trial period; and

• Staff should experience restraint as part of their training.

VI. WHAT ARE THE OBSERVATIONAL REQUIREMENTS FOR RESTRAINT?

When a patient is restrained or secluded, a specially trained person must be able to observe the patient. The condition of the patient in restraint must continually be assessed, monitored, and re-evaluated.

During seclusion, the observer may be immediately outside the patient's room--provided that the patient can fully see staff and staff can continuously observe the patient.

All staff who have direct patient contact must have ongoing education and training in the proper and safe use of restraint application and techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of restraints.

In facilities licensed, operated, or contracted for by DMH, staff must check a patient in mechanical restraint or seclusion every 15 minutes for comfort, body alignment and circulation.

VII. WHAT DOCUMENTATION IS NECESSARY FOR RESTRAINT?

• Each time restraint is ordered or renewed, the authorizer must record the reason for its use on a form.
• Within 24 hours of being restrained, the patient must receive a copy of the restraint form and be permitted to attach comments concerning the use of restraint.
• The form and the patient's comments must be placed in the patient's chart and a copy sent to the Commissioner of DMH, who must review and sign them within 30 days.
• The hospital must report to the federal Health Care Finance Agency any death that occurs while a patient is restrained or in seclusion, or where it is reasonable to assume that a patient's death is a result of restraint and seclusion.

VIII. WHAT SHOULD YOU DO IF YOU BELIEVE YOU HAVE BEEN ILLEGALLY RESTRAINED?

If you believe that you were illegally restrained while at a program or facility operated

by, contracted for, or licensed by DMH, ask to speak with the Human Rights Officer. You may also file a written complaint with the Person in Charge of the program or facility. You can give your complaint to any facility employee; he or she must forward it to the Person in Charge. If you are dissatisfied with the response of the Person in Charge and believe that additional fact-finding should occur, you have 10 days to request reconsideration. You also may file an appeal to a higher level up to 10 days after receiving a decision. The person to whom the appeal is made depends upon the type of complaint and the type of facility. In most cases, you have the right to a further appeal, which must be filed within 10 days of receiving the appeal decision. If you have questions about the complaint process, contact the Human Rights Officer or the Mental Health Legal Advisors Committee (1-800-342-9092).

Mental Health Legal Advisors Committee

294 Washington Street, Suite 320

Boston, MA 02108

(617) 338-2345

(800) 342-9092

Intake Hours: Monday & Wednesday 10:00 a.m. to 1:00 p.m.