Section 22-A506. INITIATING THE USE OF FOUR-POINT AND FIVE-POINT RESTRAINTS OR SECLUSION

 

506.1Unless otherwise specified in this section or in federal regulations, only a physician or a physician assistant, may order the use of restraints or seclusion. Such orders shall be in writing, except as set forth in § 506.2.

 

506.2In emergency situations in which a physician or physician assistant is not immediately present, a consumer may be placed in restraints or seclusion by a registered nurse (RN) before a written physician's order is obtained. In such cases:

 

(a)A verbal order shall be obtained from the attending or treating physician or physician assistant and documented immediately. If a verbal order is not obtained from the attending or treating physician or physician assistant within fifteen (15) minutes, the restraints or the seclusion shall be terminated;

 

(b)The RN in charge shall document as soon as possible, but within one (1) hour of the emergency order:

 

(1)Justification for the use of restraints or seclusion;

 

(2)Alternative strategies which failed to manage the consumer's behavior or why other strategies were considered but deemed impractical or unsafe;

 

(3)The consumer's current behaviors and mental and emotional status; and

 

(4)The consumer's physical status;

 

(c)The physician or physician assistant issuing the verbal order shall conduct a face-to-face assessment of the consumer within one (1) hour of the consumer being placed into restraints or seclusion; and

 

(d)If the physician or physician assistant does not conduct the face-to-face assessment within one hour of initiation of the restraints or seclusion so as to confirm the initial verbal order, the consumer shall be released at that time.

 

506.3The physician or physician assistant ordering the restraints or seclusion shall be available for consultation with MH provider staff throughout the period the consumer is restrained or secluded.

 

506.4Any order for the use of restraints or seclusion shall not exceed the following durational limitations:

 

(a)Four (4) hours for adults;

 

(b)Two (2) hours for children and adolescents nine (9) to seventeen (17) years of age; and

 

(c)One (1) hour for children under nine (9) years of age.

 

506.5Any orders for restraints or seclusion may only be renewed for up to a maximum of twenty-four (24) hours.

 

506.6If the emergency precipitating the use of restraints or seclusion with the consumer continues beyond the limitations of the initial order, the RN shall immediately contact the physician or physician assistant to receive further instructions.

 

506.7If the emergency precipitating the use of restraints or seclusion ends and the restraints or seclusion are discontinued before the expiration of the original order, a new order shall be obtained prior to reinitiating seclusion or reapplying restraints.

 

506.8Any new order for the use of restraint or seclusion, or any order continuing the use of a specific restraint or seclusion for a consumer, or order for the use of a new restraint or placement in seclusion following expiration of an initial order for restraint or seclusion shall be given in accordance with this section.

 

506.9Each written order for restraints and seclusion shall state:

 

(a)The name of the physician or physician assistant giving the order;

 

(b)The date and time the written order was given;

 

(c)Whether the order was for the "initial" implementation of a restraint or placement in seclusion or the "continued" use of a restraint or seclusion;

 

(d)The specific restraints (four-point or five-point) or form of seclusion ordered, including the authorized duration of the restraints or seclusion;

 

(e)Any special instructions needed due to the consumer's medical condition, physical disability, or history of abuse;

 

(f)If required, the need for monitoring of specific medical conditions or more frequent monitoring of vital signs; and

 

(g)The behavioral criteria for discontinuation of restraints or seclusion.

 

506.10For each order for restraint or seclusion, the physician or physician assistant shall also document in the consumer's clinical record, a note separate from the order, which shall include:

 

(a)Any less restrictive techniques, such as behavioral interventions or nonphysical interventions used, attempted, or considered prior to ordering the use of restraints or seclusion, as well as the reasons those techniques were not used or were ineffective;

 

(b)Whether there are any pre-existing medical conditions or any physical disabilities that would place the consumer at potentially greater risk during the use of restraints or seclusion;

 

(c)To the extent known, whether the consumer has a history of trauma, sexual, or physical abuse that would place the consumer at greater psychological risk during the use of restraints or seclusion;

 

(d)The basis, including a description of the consumer's behavior and the circumstances leading to the use of restraint or seclusion, and justification for ordering the use of the specific restraint or seclusion;

 

(e)A summation of the consumer's mental status at the time of the face-to- face evaluation by the physician; and

 

(f)How the consumer was informed of the behavioral criteria for discontinuation of restraints or seclusion.

 

506.11The criterion for release of a consumer from restraints or seclusion is that the consumer no longer presents an imminent risk of serious injury to self or others, rather than that a period of time has passed.

 

authority

Sections 114 and 209 of the Mental Health Service Delivery Reform Act of 2001, effective December 18, 2001 (D.C. Law 14-56; D.C. Official Code §§ 7-1131.14 and 1231.09 (2001 ed.)).

source

Emergency and Proposed Rulemaking published at 51 DCR 8691 (September 3, 2004)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 51 DCR 11863 (December 31, 2004)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 52 DCR 5957 (June 24, 2005)[EXPIRED]; as amended by Final Rulemaking published at 52 DCR 7229 (August 5, 2005).