Receiving facilities are governed by other federal and state laws or accreditation standards as well as their own policies and procedures. When in conflict, whichever applies to a facility and is most stringent and/or protective of the person’s rights should be followed.

Seclusion and Restraint

Presented by LSF Health Systems, Northeast and North Central Florida’s Managing Entity December 2014

 To obtain a working knowledge of seclusion and restraint in order to ensure provider compliance with state standards and regulations regarding the reporting of events at state-contracted community substance abuse and mental health treatment facilities.

Learning Objective

 Crisis Stabilization Units (CSU) and Short-Term Residential Treatment facilities (SRT) licensed under Chapter 394, Part IV, FS. They are also governed by 65E-12, F.A.C.

 Any agency licensed under 65D-30.005 (standards for Addiction Receiving Facilities) is also required to adhere to the standards and requirements of 65E-5.180 (7), F.A.C. and, therefore, must report SANDR data.

 Additionally, any agency licensed under 65D-30, which exercises control of aggression, is also required to report data.

Source: PAM 155-2 , Chapter 14

Legislative Authority – Who Must Comply

It is the policy of Florida that the use of seclusion and restraint on consumers is justified only as an emergency safety measure to be used in response to imminent danger to the client or others. THEREFORE, it is the intent of the Florida Legislature to achieve an ongoing reduction in the use of restraint and seclusion in programs and facilities serving persons with mental illness.

State of Florida Department of Children & Families Baker Act Handbook and User Reference Guide • 2014

Legislative Intent

Seclusion

 The physical segregation of a person in any fashion or involuntary isolation of a person in a room or area from which the person is prevented from leaving. The prevention may be a physical barrier or by a staffer who is acting in a manner so as to prevent the person from leaving the room or area.

Restraint

 A physical device, method or drug used to control behavior. A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the individual’s body so that he or she cannot easily remove the restraint and which restricts freedom of movement or normal access to one’s body.

Definitions

Seclusion – What it isn’t

 Seclusion does not mean isolation due to a person’s medical condition or symptoms.

Restraint – What it isn’t

 Restraint does not include physical devices, such as orthopedically prescribed appliances, surgical dressings and bandages, supportive body bands or other physical holding when necessary for routine physical examinations and tests; or for purposes of orthopedic, surgical or other similar medical treatment; when used to provide support for the achievement of functional body position or balance; or when used to protect a person from falling out of bed.

More Definitions

• Use of a medication to control the person’s behavior or to restrict his or her freedom of movement

and which is not part of the standard treatment regimen of a person with a

•

diagnosed mental illness

. Physically holding a person during a procedure to forcibly administer psychotropic medication is a physical restraint. ETOs (Emergency Treatment Orders) are not the same as chemical restraints.

Chemical Restraint

 A facility can’t use seclusion/restraint for punishment, to compensate for inadequate staffing or for the convenience of the staff.

 Persons have a right to be free from seclusion and restraints, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff.

Consumer Rights

 Seclusion or a restraint can only be used in emergency conditions, if needed, to ensure the consumer’s physical safety and less restrictive interventions have been determined to be ineffective.

 Facilities shall ensure that all staff are made aware of these restrictions on the use of seclusion/restraint and shall maintain records demonstrating this information has been conveyed to individual staff.

Consumer Rights

Staff must be trained as part of orientation (within 30 days) and subsequently on at least an annual basis. Relevant competency must be demonstrated before participating in a seclusion/restraint event or related assessment, or before monitoring/providing care during an event.

Direct Care Staff Training

DCF has adopted rules establishing forms/procedures relating to rights/privileges of persons seeking mental health treatment from Baker Act facilities.

Recommended Reading

CFOP 155-20

 Use of Seclusion in Mental Health Treatment Facilities Last Revision June 9, 2014

CFOP 155-21

 Use of Restraint in Mental Health Treatment Facilities Last Revision Oct. 25, 2012 This training material highlights key standards; please read both operating procedures in full to gain a thorough understanding of all Seclusion & Restraint requirements

Know Florida’s Guidelines

 Health and safety come first . When a consumer demonstrates a need for immediate medical attention in the initiation or course of an event, medical priorities supersede psychiatric priorities, including the immediate discontinuation of seclusion or restraint.  Seclusion and restraint will be guided by principles of trauma-informed care : assessment of traumatic histories and symptoms; recognition of culture and practices that are re-traumatizing; processing the impact of an event with the consumer; and addressing staff training needs to improve knowledge and sensitivity.

Standards

Do’s

      Develop and use a Personal Safety Plan for each admission.

Use de-escalation and physical management techniques taught by the facility. Use minimum amount of force necessary when initiating use of restraints .

Monitor the physical and psychological well-being of the consumer during an event: respiratory and circulatory status, skin integrity, vital signs, specific requirements. Maintain active certification in CPR for staff members.

Establish and utilize a Seclusion and Restraint Oversight Committee. Wear gloves, masks or clear face shields for infection control.

Don’ts

    Do not use seclusion and restraint simultaneously for people younger than 18 years old. Do not space yourself farther than arm’s reach from a consumer whose restraints prevent him/her from protective extension of arms when falling. Do not restrain consumers in a prone position. If prone to prevent imminent serious harm, the consumer will be repositioned to a sitting, standing or supine position as quickly as possible.

Do not place objects over a consumer’s face. Do not secure hands behind the back unless to prevent serious injury.

A Closer look at the Personal Safety Plan

 The plan will be completed upon admission or as soon as the consumer is stable enough to complete it with staff assistance.  The plan will be filed in the consumer’s chart and reviewed at least every 12 months based on admission date to determine if changes are necessary.  Review of the personal safety plan will be documented by the recovery team within 2 working days of a seclusion or restraint event, and updated if necessary.  All staff will be aware of and have ready access to each individual’s personal safety plan.

Safety Plan Requirements

 The seclusion and restraint process shall show evidence that the resident’s choice alternatives, as identified on the personal safety plan form, have been considered.  Any preference expressed by the consumer regarding the gender of the observing staff person shall be honored when possible and clinically appropriate.

Sometimes necessary, but must be minimized. DURATION WILL BE ONLY LONG ENOUGH TO GAIN CONTROL. Sitting on top of any part of a consumer during containment is prohibited. The weight of the staff shall be placed to the side of the consumer. Care must be taken not to place any pressure on the individual’s chest, back, lungs, diaphragm or stomach. Nursing staff must be called to assess the resident as soon as possible, within 15 minutes of the restraint and at least every hour thereafter while in restraint.

Containment, or “take-down”

Seclusion and Restraint can be implemented through an order by a physician or other licensed independent practitioner (ARNP or P.A.), if permitted by facility protocol. Seclusions may be initiated prior to obtaining a written order if the physician is not immediately available. Restraint may be initiated prior to a written order only in an emergency.

Initiating ETO

(Emergency Treatment Orders)

 Seclusion or Restraint may be initiated prior to obtaining a written order only if the resident presents an immediate danger to self or others.  An RN or highest level trained staff member who is immediately available may initiate in an emergency.  If someone other than an ARNP or RN initiates restraint, the RN or ARNP will assess the need within 15 minutes of initiation.  A physician/ARNP/RN must conduct a face-to face exam within 1 hour of initiation. This face-to face may be delegated to a trained RN.

Immediate danger

 Before placing a resident in seclusion, staff shall check the seclusion room to ensure it is safe and free of unsafe items.  Same-gender staff will search the consumer for potentially dangerous objects.

 Resident must be clothed appropriately.

 The initiating staff person or RN/physician must inform the consumer of the behavior that precipitated the seclusion and explain the behavioral criteria necessary for release. Document release criteria in the physician’s order.

Seclusion Requirements

 Written order for restraint of residents age 18 and over is limited to 4 hours.  Time limit for residents age 9 through 17 is 2 hours.  Order can be extended up to 4 more hours after review by an ARNP or physician, or by an RN who has physically observed and evaluated the consumer.  Original order may only be extended for a total 24 hours. Then a new order must be written and signed within 24 hours.  After an order has expired, the resident must be seen by a physician, ARNP or PA before a new order can be written. The facility’s administrator must be notified the next business day.

Restraint Requirements

For both Seclusion and Restraint …

 Be written on the Order Sheet and included in the resident’s record.

 Specify the facts and behaviors justifying the intervention.

 Identify the time of initiation and expiration.

 Specify the type of intervention.  Include special care or monitoring instructions.

 Include the criteria for release.

For Restraint…

 Specify the type of restraint ordered.  Specify the positioning of the consumer for respiratory and other medical safety considerations.

 Specify the physical proximity of the staff member assigned continuous visual observation (i.e. within arm’s length, outside the room)

Written orders shall:

 Observation of a secluded or restrained person must be ongoing with documentation of the resident’s condition made at least every 15 minutes by trained staff. Include behavior, potential injury and respiration.  At least once per hour the observation must be conducted by a nurse.

 Staff assigned to monitor must be competent to assess physical and psychological signs of distress.  Consumers must be offered opportunity to drink and to toilet, as requested.  Those in restraints must have range of motion to promote comfort.

Monitoring

* A person in restraints must not be subject to view by other consumers

      The emergency situation resulting in the event.

The less restrictive interventions attempted, or the clinical determination that they could not be safely applied.

The name and title of initiating staff member.

Date/time of initiation and release.

Resident’s response to the seclusion or restraint, including the rationale for continued use. That the resident was informed of the behavior that resulted in seclusion/restraint and the criteria necessary for release.

Document in chart and log sheet

 A consumer shall be released from seclusion or restraint as soon as he or she no longer appears to present a danger to themselves or others.

 Upon release, a nurse shall observe, evaluate and document the consumer’s physical and psychological condition.

 After an event, a debriefing process shall take place to decrease the likelihood of a future event and to provide support.

Release

 The individual shall be given the opportunity to process the event within 24 hours after release.

 Each facility will develop policies around this debriefing, which shall assess the impact of the event on the individual and help him/her identify and expand coping techniques.  Summary of the review should be placed in medical record.

 Staff involved in the event will review it by the close of the next business day after the event. The recovery team shall meet and review the consumer’s recovery plan within 2 working days. Consumer will be invited to participate.

Reviewing the event

Each facility utilizing seclusion and restraint procedures shall establish and gather an Oversight Committee that includes medical staff to conduct at least weekly reviews of each use of seclusion or restraint and monitor patterns of use. The review committee shall include a consumer or external advocate if employed or whenever possible, and shall employ an analysis and countermeasures approach.

Oversight Committee

 If seclusion or restraint contributed directly or indirectly to the consumer’s death, DCF must be notified via the IRAS system within 24 hours of the death, and the Managing Entity must be called immediately.  Please refer to CFOP 155-20, 155-21 and CFOP 215-6 for specific information on reporting a critical incident.

Death Relating to Seclusion or Restraint

 LSFHS CQI Specialist monitors the reporting of SANDR events at provider facilities, reviewing policies – including those that prohibit the use of SANDR – and offering training where needed. This includes de escalation techniques.  DCF develops quarterly reports of SANDR data which LSFHS analyzes for frequency, duration and other trends.  LSFHS collaborates with providers on best practices and shares information and success regarding reducing the use of seclusion and restraint.

Technical Assistance and Monitoring

 Providers will enter SANDR data of DCF SAMH / LSF-funded consumers into https://lsfhealthsystems.org

no later than the 10 th following the end of the reporting month, as per contract .

 Providers will enter SANDR data of non DCF/LSF-funded consumers into the SAMHIS web portal no later than the 15 14.

th following the end of the reporting month, per PAM 155-2 Chapter SANDR

Reporting SANDR data

This is the screen where saved SANDR events at provider and M.E. level will show. To enter an event, click on the link highlighted and follow prompts.

Providers must complete each entry or the system will not accept as a valid event.

Thank you for your attention and review of this important behavioral healthcare topic. We hope you have found this slide show helpful!