Primary regulation

42 CFR 482.13 and 42 CFR 482.60

Who can order it

“The use of a restraint or seclusion must be... in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order seclusion or restraint.” 42 CFR 482.13(f)(3)(ii). “The treating physician must be consulted as soon as possible, if the restraint or seclusion is not ordered by the patient's treating physician.” 42 CFR 482.13(f)(3)(ii)(B).

When does an MD have to cosign

Always. “The use of a restraint or seclusion must be... in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order seclusion or restraint.” 42 CFR 482.13(f)(3)(ii).

Is the presence of an MD required to apply

No, but “a physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention.” 42 CFR 482.13(f)(3)(ii)(C). Superseded by state law if more restrictive. 

Duration of each order

“Each written order for a physical restraint or seclusion is limited to 4 hours for adults; 2 hours for children and adolescents ages 9 to 17; or 1 hour for patients under 9. The original order may only be renewed... for up to a total of 24 hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must see and assess the patient before issuing a new order.” 42 CFR 482.13(f)(3)(ii)(D). Superseded by state law if more restrictive.

How often must they check on patients

The condition of the patient in a restraint or seclusion must be continually assessed, monitored, and reevaluated. 42 CFR 482.13(f)(5).

 When in restraint and seclusion, must be continually monitored face-to-face or by staff using both video & audio equipment and in close proximity.  42 CFR 482.13(f)(4).

Staff training required

“All staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint… and alternative methods for handling behavior, symptoms, and situation that traditionally have been treated through the use of restraints or seclusion.” 42 CFR 482.13(f)(6).

Restraint

Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that s/he cannot easily remove that restricts freedom of movement or normal access to one’s body.

42 CFR 482.13(f)(1).

Chemical Restraints

“A drug used as a restraint is a medication used to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.” 42 CFR 482.13(f)(1).

Seclusion

“Seclusion is the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.” 42 CFR 482.13(f)(1).

“A restraint and seclusion may not be used simultaneously unless the patient is… continually monitored face-to-face by an assigned staff member; or continually monitored by staff using both video and audio equipment. This monitoring must be in close proximity to the patient.” 42 CFR 482.13(f)(3)(ii).

Postural Supports

Documentation

“The hospital must report to CMS[1] 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 or seclusion.” 42 CFR 483.13(f)(7).

Alternatives required

“Seclusion and restraint can only be used in emergency situations if needed to ensure the patient's physical safety and less restrictive interventions have been determined to be ineffective [to protect the patient or others from harm].” 42 CFR 482.13(f)(2) & (3)(i).

Primary regulation

22 CCR 70577(j)

Who can order it

“[O]nly on the... order of the physician or clinical psychologist.  In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).

When does an MD have to cosign

Always.  “If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 70577(j)(2).

Is the presence of an MD required to apply

No. “In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).

Duration of each order

How often must they check on patients

“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 70577(j)(3).

Staff training required

“Psychiatric unit staff shall be involved in orientation and in-service training of hospital employees. Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.” 22 CCR 70577(l) and (m).

Restraint

“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion or mechanical devices.” 22 CCR 70059.

Chemical Restraints

Seclusion

Same as restraint.

Postural Supports

Documentation

“Record of type of restraint including time of application and removal shall be in the patient's medical record.” 22 CCR 70577(j)(5). “If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 70577(j)(2).

Alternatives required

“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 70577(j)(1).

Primary regulation

Hospital Accreditation Standards (HAS) (2005) PC.12[2]

Who can order it

“[O]rdered by a licensed independent practitioner (LIP) (“Any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges"). HAS Glossary.

Qualified, trained staff members (authorized by the hospital or permitted by state law)… may initiate.  Must obtain order from LIP as soon as possible, no longer than one hour.  PC.12.70.

When does an MD have to cosign

Is the presence of an MD required to apply

No.

LIP evaluates in-person within:

-        4 hours of initiation for adults;

-        2 hours of initiation for child 17 and under.

PC.12.90.

Thereafter, LIP conducts in-person reevaluation:

-        every 8 hours for adults;

-        every 4 hours for children under 17 years.

PC.12.110.

LIP evaluates in-person a patient released from restraint or seclusion within 24 hours of the initiation of the restraint or seclusion.  PC.12.90.

Duration of each order

Orders for restraint or seclusion are limited to:

-        every 4 hours for adults;

-        every 2 hours for children 9 -17 years;

-        every 1 hour for children under 9 year.

PC.12.100.

Extended duration restraint/seclusion

Clinical leaders notified of restraint/seclusion:

-        extending beyond 12 hours;

-        occurring two or more times within 12 hours;

-        thereafter, every 24 hours.

PC.12.120.

How often must they check on patients

-        Continuous in-person observation;

-        After first hour of seclusion only, may continuously monitor by video and audio equipment;

-        Second staff member required to observe during physical holds.

PC.12.140.

Patient assessed and assisted every 15 minutes. PC.12.130.

Staff training required

Staff is trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely.  PC.12.30.

Restraint

Any method (chemical or physical) of restricting a patient’s freedom of movement, including seclusion, physical activity, or normal access to his/her body that:

-        is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his/her legal representative has consented;

-        is not indicated to treat the patient’s medical condition or symptoms; or

-        does not promote the patient’s independent functioning.

HAS glossary.

Chemical Restraints

“The inappropriate use of a sedating psychotropic drug to manage or control behavior.” HAS glossary.

Seclusion

Included in definition of restraint.

Postural Supports

Restraint standards in acute medical and surgical (non-psychiatric) care are covered under separate requirements. PC. 11.10 – 11.100.

Documentation

Medical records document that the use of restraint or seclusion is consistent with hospital policy.  Includes specific requirements.   PC.12.170.

Alternatives required

Limited to emergencies in which there is an imminent risk of a patient physically harming him/herself, staff, or others, and nonphysical interventions would not be effective.  PC.12.60.

Primary regulation

22 CCR 71545

Who can order it

“[O]nly on the... order of the physician or clinical psychologist.  In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 71545(b).

When does an MD have to cosign

“If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 71545(b).

Is the presence of an MD required to apply

No.

Duration of each order

How often must they check on patients

“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 71545(c).

Staff training required

Restraint

“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion, medication or mechanical devices.” 22 CCR 71055.

Chemical Restraints

Same as restraint.

Seclusion

Same as restraint.

Postural Supports

Documentation

“This order shall include the reason for restraint and the type of restraint being used…. If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 71545(b).

Alternatives required

“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 71545(a).

Primary regulation

Standards for Behavioral Health Care (SBHC) (2004-2005) PC[3]12

Who can order it

“[O]rdered by a licensed independent practitioner (LIP) (“Any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges"). SBHC Glossary.

Qualified, trained staff members (authorized by the hospital or permitted by state law)…may initiate.  Must obtain order from LIP as soon as possible, no longer than one hour.

PC.12.70.

When does an MD have to cosign

Is the presence of an MD required to apply

No.

LIP evaluates in-person within:

-        4 hours of initiation for adults;

-        2 hours of initiation for child 17 and under.

                              PC.12.90.

Thereafter, LIP conducts in-person reevaluation:

-        every 8 hours for adults;

-        every 4 hours for children under 17 years.

                              PC.12.110.

LIP evaluates in-person a patient released from restraint or seclusion within 24 hours of the initiation of the restraint or seclusion.

                              PC.12.90.

Duration of each order

Orders for restraint or seclusion are limited to:

-        every 4 hours for adults;

-        every 2 hours for children 9 -17 years;

-        every 1 hour for children under 9 year.

PC.12.100.

Extended duration restraint/seclusion

Clinical leaders notified of restraint/seclusion:

-        extending beyond 12 hours;

-        occurring two or more times within 12 hours;

-        thereafter, every 24 hours.

PC.12.120.

How often must they check on patients

-        Continuous in-person observation.

-        After first hour of seclusion only, may continuously monitor by video & audio equipment.

-        Second staff member required to observe during physical holds.

PC.12.140.

Patient assessed and assisted every 15 minutes. PC.12.130.

Staff training required

Staff is trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely.  PC.12.30.

Restraint

Any method (chemical or physical) of restricting a patient’s freedom of movement, including seclusion, physical activity, or normal access to his/her body that:

-        is not a usual and customary part of a medical  diagnostic or treatment procedure to which the patient or his/her legal representative has consented,

-        is not indicated to treat the patient’s medical condition or symptoms, or

-        does not promote the patient’s independent functioning                                 

SBHC glossary

Chemical Restraints

“The inappropriate use of a sedating psychotropic drug to manage or control behavior.” SBHC glossary.

Seclusion

Postural Supports

Restraint standards in acute medical and surgical (non-psychiatric) care are covered under separate requirements. PC. 11.10.

Documentation

Clinical/case records document that the use of restraint or seclusion is consistent with organization policy.  Includes specific requirements.   PC.12.170.

Alternatives required

Limited to emergencies in which there is an imminent risk of a patient physically harming him/herself, staff, or others, and nonphysical interventions would not be effective.  PC.12.60.

Primary regulation

22 CCR 77103

Who can order it

“[S]hall only be used upon a physician's or clinical psychologist's written or verbal order, except under emergency circumstances. Under emergency circumstances behavioral restraint may be applied and then an order obtained as soon as possible, but at least within one hour of application.” 22 CCR 77103(b). 

When does an MD have to cosign

“Telephone orders shall be… within twenty-four (24) hours, weekends and holidays excepted, signed by the prescriber.” 22 CCR 77103(b).

Is the presence of an MD required

No.

Duration of each order

“Orders for behavioral restraint and seclusion shall be in force for not longer than twenty-four (24) hours.” 22 CCR 77103(d).

How often must they check on patients

“[Patient]… shall remain in staffs' line of vision….” 22 CCR 77103(f).  “[P]atient… shall be checked at least every 15 minutes by professional staff….”  22 CCR 77103(g).

Staff training required

Restraint

No physical restraints with locking devices shall be used or available for use unless approved by State Fire Marshall.  22 CCR 77101.

Chemical Restraints

Seclusion

“Seclusion means isolation… in a locked area, for the purpose of modifying behavior.” 22 CCR 77029.

Exclusionary timeout means removing a patient from an activity to another area in the same room or vicinity for a period of time contingent on a specific maladaptive behavior.  22 CCR 77010.  Exclusionary timeout is considered to be a physical restraint.  22 CCR 77101.

Postural Supports

“Postural supports means a method other than orthopedic braces used to assist patients to achieve proper body position and balance.”  22 CCR 77021.

Treatment restraint means the use of a restraining device during medically prescribed treatment or diagnostic procedures. 22 CCR 77033.

Documentation

“Telephone orders… shall be recorded immediately in the patient's health record….” 22 CCR 77103(b). “A written record shall be kept of [required] checks and maintained in the individual patient's health record.” 22 CCR 77103(g).

Alternatives Required

“Behavioral restraint and seclusion shall only be used as a measure to protect the patient from injury to self or others.” 22 CCR 77103(a).

Other

“Behavioral and treatment restraints shall be utilized only with patients being treated pursuant to Sections 5150 et seq. of the Welfare and Institutions Code or who are judicially committed.” 22 CCR 77103(i).

Primary regulation

22 CCR 72319

Who can order it

“Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care.... [I]n an emergency which threatens to bring immediate injury to the patient or others… an order may be received by telephone.” 22 CCR 72319(i)(2).

When does an MD have to cosign

[I]n an emergency which threatens to bring immediate injury to the patient or others… an order may be received by telephone, and shall be signed within 5 days.” 22 CCR 72319(i)(2).

Is the presence of an MD required

No.

Duration of each order

“Each patient care plan which includes the use of physical restraint for behavioral control shall specify… the time limit for the use of the method.”  22 CCR 72319(i)(2)(B).

How often must they check on patients

“Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area.” 22 CCR 72319(i)(2)(C).

Staff training required

Restraint

“Only acceptable form of physical restraint shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices.”  22 CCR 72319(c).

“No restraint with locking devices shall be used or available for use in skilled nursing facility.”  22 CCR 72319(e).

Chemical Restraints

vs.

Psychotherapeutic Drugs

“A drug used to control behavior and used in a manner not required to treat the patient’s medical symptoms.”  22 CCR 72018.

“Psychotherapeutic drug means a medication to control behavior or to treat thought disorder processes.”  22 CCR 72092.

When drugs (including PRNs) are used to restrain or control behavior or to treat a thought disorder, the following shall apply:

-        “The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record.” 22 CCR 72319(j)(1).

-        “The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions.” 22 CCR 72319(j)(2).

-        “The data collected shall be made available to the prescriber in a consolidated manner at least monthly.” 22 CCR 72319(j)(3).

Seclusion

“Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed.” 22 CCR 72319(f).

Postural Supports

“Postural support means a method other than orthopedic braces used to assist patients to achieve proper body position and balance.  Postural supports may only include soft ties, seat belts, spring release trays, or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints.” 22 CCR 72319(k).

“Treatment restraints may be use for the protection of the patient during treatment and diagnostic procedures….  Treatment restraints shall be applied for no loner than the time required to complete the treatment.”  22 CCR 72319(i)(1).

Documentation

“Full documentation of the episode leading to the use of physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record.” 22 CCR 72319(i)(2).

“Each patient care plan…[for] physical restraint for behavioral control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method.”  22 CCR 72319(i)(2)(B).

Alternatives Required

“Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied.” 22 CCR 72319(i)(2)(A).

Primary regulation

22 CCR 72461 (Must also comply with 22 CCR 72319)

Who can order it

“Restraint and seclusion shall only be used on the signed order of a physician.… In a documented case of emergency, which threatens to bring immediate injury to the patient or others, a restraint may be applied, and a physician shall give an order for application of the restraint within one hour. A physician may give the order by telephone.” 22 CCR 72461(a).

When does an MD have to cosign

In a documented case of emergency, which threatens to bring immediate injury to the patient or others, a restraint may be applied, the physician shall sign the telephone order “within 5 days.” 22 CCR 72461(a).

Is the presence of an MD required

No.

Duration of each order

Orders “shall be renewed every 24 hours.” 22 CCR 72461(a).

How often must they check on patients

“Patients placed in restraint shall be observed by qualified treatment personnel at least every half hour.” 22 CCR 72463(a)(2). “Patients placed in seclusion shall be observed by qualified treatment personnel at least every half hour.” 22 CCR 72463(b)(1).

Staff training required

Restraints

Mechanical or behavior restraints are… any apparatus that interferes with the free movement of a patient.  22 CCR 72459(a).

Physical restraint means restraint to control an acutely disturbed person to prevent the person from causing harm to self or others.  22 CCR 72459(a)(1).

Only the following types of physical restraint may be used:

-        Soft tie consisting of cloth…

-        Mittens without thumbs…securely fastened around wrist with a tie

-        Cloth vests…

-        Belts and cuffs, well padded, used to control a seriously disturbed, assaultive patient

22 CCR 72459(a)(1).

Chemical Restraints

“Medication shall not be used as punishment, as a substitute for a program or for the convenience of staff.” 22 CCR 72463(c).

Seclusion

“… [S]eclusion shall only be used as [an] emergency [measure] to protect the patient from injury to self or to others…. [S]eclusion shall not be used as punishment or for the convenience of staff.” 22 CCR 72457(a).

Postural Supports

“A physical restraint shall not be confused with a postural support as defined in Section 72319(k).” 22 CCR 72459(a)(1).

“Postural support means a method other than orthopedic braces used to assist patients to achieve proper body position and balance.  Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints.” 22 CCR 72319(k).

Documentation

“A daily log shall be maintained… indicating the name of the patient for whom behavior restraint or seclusion is ordered….” 22 CCR 72461(b).

“Full documentation of the episode leading to the behavior restraint or seclusion, the type of behavior restraint or seclusion used, and the name of the individual applying such measures shall be entered in the patient's health record.” 22 CCR 72461(c).

Required “observation shall be noted and initialed in the patient's health record following each observation.” 22 CCR 72463(a)(2).

Alternatives Required

“Restraint and seclusion shall only be used as emergency measures to protect the patient from injury to self or to others,” including during treatment & diagnostic procedures and to prevent falls out of bed or chairs or otherwise injuring themselves.”  22 CCR 72457(a).

“Restraint and seclusion shall not be used as punishment or the convenience of the staff.” 22 CCR 72457(a).

Primary regulation

42 CFR 483.450

Who can order it

“The facility may employ physical restraint only:

(i)             as an integral part of an individual program plan;

(ii)           as an emergency measure; or

(iii)         as a health related protection prescribed by a physician.” 42 CFR 483.450(d)(i) to (iii).

When does an MD have to cosign

Is the presence of an MD required

“Authorizations to use or extend restraints as an emergency must be obtained as soon as the client is restrained or is stable.” 42 CFR 483.450(d)(2)(ii).

Duration of each order

“Authorizations to use or extend restraints… must be in effect no longer than 12 consecutive hours.” 42 CFR 483.450(d)(2)(i).

“Placement of a client in a time-out room must not exceed one hour.” 42 CFR 483.450(c)(2).

How often must they check on patients

“[A]t least every 30 minutes by staff trained in the use of restraints.” 42 CFR 483.450(d)(4). A client placed in time-out (seclusion) must be “under the direct constant visual supervision of designated staff.” 42 CFR 483.450(c)(ii).

Staff training required

“The facility must develop and implement written policies and procedures that govern the management of inappropriate client behavior.”  42 CFR 483.450(b)(1).

Chemical Restraints

“The facility must not use drugs in doses that interfere with the individual client's daily living activities. Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team and used only as an integral part of the client's individual program plan…. Drugs used for control of inappropriate behavior must not be used until it can be justified that the harmful behavior clearly outweighs the potentially harmful effects of the drugs.  Drugs... must be monitored closely... and gradually withdrawn at least annually.” 42 CFR 483.450(e).

Seclusion

“A client may be placed in a room from which egress is prevented only if… the placement is a part of an approved systematic time-out program… the client is under the direct constant visual supervision of designated staff… the door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member.” 42 CFR 483.450(c)(1). 

Placement in time out room must not exceed 1 hour. 42 CFR 483.450(c)(1). 

Postural Supports

Documentation

“[A] record of checks and usage must be kept.” 42 CFR 483.450(d)(4).

“A record of time-out activities must be kept.” 42 CFR 483.450(c)(4).

Alternatives Required

“Techniques to manage inappropriate client behavior must never be used for disciplinary purposes, for the convenience of staff or as a substitute for an active treatment program.” 42 CFR 483.450(b)(3).

Other

“Opportunity for motion and exercise must be provided for a period of not less than 10 minutes during each two hour period in which restraint is employed.” 42 CFR 483.450(d)(6).

Primary regulation

22 CCR 73403

Who can order it

“[S]hall only be used on the signed order of a physician…. In a clear case of medical emergency, a physician may give the order by telephone.” 22 CCR 73409(a).

When does an MD have to cosign

Always. “[S]hall only be used on the signed order of a physician…. In a clear case of medical emergency, a physician may give the order by telephone. In such an event, the physician shall sign the order within 48 hours.” 22 CCR 73409(a).

Is the presence of an MD required

No.

Duration of each order

“[O]rder… shall be renewed every 24 hours.” 22 CCR 73409(a).

How often must they check on patients

“Patients placed in restraint shall be observed by qualified treatment personnel at least every half hour.” 22 CCR 73407(a)(3). “Patients placed in seclusion shall be observed by qualified treatment personnel at least every hour.” 22 CCR 73407(a)(4).

Staff training required

Restraint

Mechanical or behavior restraint consists of any apparatus that interferes with the free movement of a patient.  Only the following types of restraint may be used:

-        soft tie consisting of cloth;

-        mittens without thumbs securely fastened around the wrist with a small tie;

-        tie jackets of sleeveless cloth;

-        restraining sheet of a wide piece of muslin over body of patient;

-        belts and cuffs to control seriously disturbed, assaultive patient.

22 CCR 73405.

Restraint means controlling a patient’s physical activity in order to protect the patient or others from injury.  22 CCR 73095.

Chemical Restraints

Means a drug used to control behavior and used in a manner not required to treat the patient’s medical symptoms.  22 CCR 73012.2.

Psychotherapeutic drug means a medication to control behavior or to treat thought disorder processes.  22 CCR 73090.

Seclusion

“Except in rooms approved by the [Department of Health Services] for seclusion, patient's rooms shall not be locked when occupied.” 22 CCR 73407(a)(2).

Postural Supports

Documentation

“A daily log shall be maintained in each facility… indicating the name of the patient… full documentation of the episode leading to the behavior restraint or seclusion, the type of the behavior restraint or seclusion used, the length of time and the name of the individual applying such measures.” 22 CCR 73409(b).

When in restraints, observation [every 30 minutes] shall be noted and initialed in patient record.  22 CCR 63407(a)(3).

When in seclusion, observation [every hour] shall be noted and initialed in patient record.  22 CCR 63407(a)(4).

Alternatives Required

“Restraint and seclusion shall only be used as emergency measures to protect the patient from injury to himself or others…. [S]hall not be used as punishment or as a substitute for more effective medical and nursing care program.” 22 CCR 73403(a).

Primary regulation

22 CCR 76325-76331

Who can order it

“[O]nly upon a physician's or clinical psychologist's written or telephone order.” 22 CCR 76327(a). “There shall be no P.R.N. orders….” 22 CCR 76327(d).

When does an MD have to cosign

Always. “[O]nly upon a physician's or clinical psychologist's written or telephone order. Telephone orders… shall be signed by the prescriber within 48 hours.” 22 CCR 76327(a).

Is the presence of an MD required

“Telephone orders… shall be signed by the prescriber within 48 hours.” 22 CCR 76327(a).

Duration of each order

“Orders for physical restraints shall be in force for not longer than 12 hours.” 22 CCR 76327(b).

Extended duration restraint/seclusion

“Orders for treatment restraints shall be in force for not longer than seven days.” 22 CCR 76327(c).

How often must they check on patients

“[S]hall be checked every 30 minutes….” 22CCR 76329(a)(4). 

“Clients shall be restrained only in an area that is under direct observation of staff....” 22 CCR 76329(a)(6).

Staff training required

“[S]hall be… conducted only by staff who have received documented training in behavior modification.” 22 CCR 76331(a)(6).

Restraint

Physical restraint means restraint to control an acutely disturbed person to prevent the person from causing harm to self or others.  Types:

-        wide piece of muslin over body;

-        mittens;

-        soft ties;

-        jacket of sleeveless cloth.

Includes restraint of hands, body or feet separately or in combination and totally enclosed cribs.

22 CCR 76325(a)(1).

No restraint with locking devices shall be used or available.  22 CCR 76327(h).

Chemical Restraints

Means the use of psychotropic or behavior-modifying drugs use to prevent a client from exhibiting an identified maladaptive behavior.  22 CCR 76325(a)(2).

“Psychotropic or behavior-modifying drugs shall be

used only as an integral part of an individual program plan that is designed by an interdisciplinary team to lead to a less restrictive way of managing and ultimately to the elimination of those behaviors for which the drugs are employed.”  “Each program plan utilizing a psychotropic drug... [s]hall... [b]e a time-limited (no more than 30 days) prescription by a physician.... [S]hall include written justification for the continued use of the drug.” 22 CCR 76329(b)(2)(A).

P.R.N. prescriptions shall be subject to same requirements. 22 CCR 76329(b)(3).

Seclusion

Seclusion, defined as placement of a client alone in a locked room, shall not be employed. 22 CCR 76327(f).

Postural Supports

“Postural supports mean devices other than orthopedic braces used to assist clients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth sheeting and shall only be used to improve a client's mobility and independent functioning, rather than restrict movement. These devices shall not be considered restraints.” 22 CCR 76335.

Treatment restraint means restraint during medically prescribed treatment or diagnostic procedure.  This may be accomplished by soft ties only.  22 CR 76325(a)(3).

Documentation

“Telephone orders… shall be recorded immediately.” 22 CCR 76327(a). “The client's record shall include a recording with justification and authorization of all periods of restraint.” 22 CCR 76327(e).

Alternatives Required

“Restraint shall not be used as a punishment, as a substitute for more effective programming or for the convenience of the staff.” 22 CCR 76327(a).

Other

“[S]hall be used only as an integral part of an individual program plan that is designed by an interdisciplinary team to lead to a less restrictive way of managing, and ultimately to the elimination of, behavior for which the restraint is applied.” 22 CCR 76329(a)(1).

Primary regulation

22 CCR 76866-76869

Who can order it

“[O]nly upon a written or telephone order of a physician or clinical psychologist.” 22 CCR 76867(a).  “There shall be no P.R.N. (as needed) orders for physical restraints.” 22 CCR 76867(c).

When does an MD have to cosign

“Telephone orders shall be signed by prescriber within five days.” 22 CCR 76867(a). 

Is the presence of an MD required

No. “Telephone orders… shall be signed by the prescriber within five days.” 22 CCR 76867(a).

Duration of each order

“[S]hall be in force for not longer than 12 hours.” 22 CCR 76867(b).

How often must they check on patients

“[S]hall be checked every 15 minutes….” 22 CCR  76868(a)(2). 

“Clients in restraint shall remain in staff's constant line of vision....” 22 CCR 76868(a)(4).

Staff training required

“Behavior management programs shall be approved by the [Department of Developmental Services] prior to implementation....” 22 CCR 76869(a).

Restraint

Devices used to control a client’s physical activity in order to prevent the client from causing harm to self or others. 22 CCR 76827.

Only the following types shall be used:

-        mittens and/or soft ties;

-        jackets consisting of sleeveless cloth webbing.

22 CCR 76866(a).

Totally enclosed cribs and bared enclosures shall not be used.  22 CCR 76866(b).

No restraint with locking devices shall be used.  22 CCR 76867(f).

Chemical Restraints

Means the use of psychotherapeutic or behavior modifying drugs used to prevent a client from exhibiting an identified maladaptive behavior.  22 CCR 76803.

“Chemical restraints shall not be used as a substitute for active treatment.” 22 CCR 76866(c).

“Psychotherapeutic or behavior-altering drugs shall be used only as an integral part of an individual service plan that is designed by an interdisciplinary professional staff/team to lead to a less restrictive way of managing maladaptive behavior and ultimately to the elimination of those behaviors for which the drugs are employed.” 22 CCR 76868(b)(2).  “Each individual service plan utilizing a psychotropic drug... [s]hall... be a time-limited prescription of no more than 30 days, ordered by a physician…”  22 CCR 76868(b)(2)(A).

“P.R.N. prescriptions shall be subject to Section 22 CCR 76896.” 22 CCR 76868 (b)(3).

Seclusion

“Clients shall not be placed in a room that is locked or where the door is held closed by any means.” 22 CCR 76867(e).

Exclusionary time out means removing a client from an activity to another area in the same room or vicinity for a period of time contingent on a specific maladaptive behavior.  22 CCR 76816.

Postural Supports

“Postural supports are devices other than orthopedic braces used to assist clients to achieve proper body position and balance.” 22 CCR 76828 & 76871(a).

Shall not be considered restraints.  22 CCR 76828.

Documentation

“Telephone orders shall be recorded immediately….” 22 CCR 76867(a). “The client's record shall include an entry noting the time of application and removal of restraints, justification for and authorization of all periods of restraints and signature of the person applying the restraints.” 22 CCR 76867(d).

Alternatives Required

“Restraints shall only be used as temporary emergency measures to protect the client from injury to self or others…. Restraints shall not be used as a punishment, a substitute for more effective programming or for the convenience of the staff.” 22 CCR 76867(a).

Primary regulation

15 CCR 3268

Who can order it

“The choices [available to an employee when selecting a reasonable force option]… include, but are not necessarily limited to… chemical agents and/or other immobilization devices.” 15 CCR 3268(a)(6)(B).  “Employees may use reasonable force as required in the performance of their duties.…” 15 CCR 3268(b). “Authority to order... administrative segregation may not be delegated below the staff level of correctional lieutenant except when a lower level staff member is the highest ranking official on duty.” 15 CCR 3336.

When does an MD have to cosign

Not required.  “Employees may use reasonable force as required in the performance of their duties.” 15 CCR 3268(b).

Is the presence of an MD required

No. “The choices [available to an employee when selecting a reasonable force option]… include, but are not necessarily limited to… chemical agents and/or other immobilization devices….” 15 CCR 3268(a)(6)(B).  “Employees may use reasonable force as required in the performance of their duties....” 15 CCR 3268(b).

Duration of each order

Reasonable force is “[t]he force that an objective, trained and competent correctional employee, faced with similar facts and circumstances, would consider necessary to subdue an attacker, overcome resistance, effect custody, or gain compliance with a lawful order.”  15 CCR 3268(a)(1).  Administrative segregation is reviewed after 10 days, and every 30 days thereafter. 15 CCR 3335(c).

How often must they check on patients

Staff training required

Chemical Restraints

“The choices [available to an employee when selecting a reasonable force option]… include, but are not necessarily limited to… chemical agents and/or other immobilization devices.…” 15 CCR 3268(a)(6)(B). 

Seclusion

“Administrative segregation may be accomplished by confinement… to any single cell unit capable of providing secure segregation.” 15 CCR 3335.

Postural Supports

Documentation

“Use of restraint equipment by direction of medical staff shall be fully documented in the institution medical file of the restrained inmate.” 15 CCR 3268.2(d).  “An Administrative Segregation Log… will be maintained in each administrative segregation unit….” 15 CCR 3344(a).

Alternatives Required

“Mechanical restraints shall not be… (1) used as punishment… (2) placed around a person's neck… (3) applied in a way likely to cause undue physical discomfort or restrict blood flow or breathing. e.g., hog-tying.” 15 CCR 3268.2(b).

Primary regulation

22 CCR 79801

Who can order it

“[S]hall only be used on a written or verbal order of a psychiatrist or clinical psychologist. Clinical restraint shall additionally require a physician's or physician's assistant's or a nurse practitioner's (operating under the supervision of a physician) written or verbal approval…. Under emergency circumstances clinical restraint or clinical seclusion may be applied, and then an approval and/or order must be obtained….” 22 CCR 79801(b).

When does an MD have to cosign

Always. “Under emergency circumstances clinical restraint or clinical seclusion may be applied, and then an approval and/or order must be obtained... at least within one hour of application.” 22 CCR 79801(b).

Telephone orders… must be signed within 24 hours.  22 CCR 79801(b).

Is the presence of an MD required

No.

Duration of each order

“[S]hall be in force for no longer than twenty-four (24) hours.” 22 CCR 79801(e).

How often must they check on patients

“A physician shall complete a medical assessment of an inmate-patient at the earliest opportunity but no later than within twenty-four (24) hours.…” 22 CCR 79801(c).  “[S]hall be physically checked at least every fifteen (15) minutes by nursing staff.…22 CCR 79801(g).  “[S]hall be placed… only in an area that is under direct observation of staff.” 22 CCR 79801(j).

Staff training required

“Each correctional treatment center shall have an ongoing educational program planned and conducted for the development of the necessary skills and knowledge for all facility personnel.” 22 CCR 79797(a).

Restraint

Means the use of a physical restraining device during the period of mental health treatment, as a measure to protect the inmate-patient from injury to self or others when alternative methods are not sufficient.  22 CCR 79511.

Chemical Restraints

Seclusion

Means isolation during the period of mental health treatment of an inmate-patient in a separate, locked area… for the purpose of preventing injury to self or others.  22 CCR 79513.

“Removing an inmate-patient… to another unlocked area… shall not be considered clinical seclusion.” 22 CCR 79801(d).

Postural Supports

“Treatment restraint means the use of a restraining device during medically prescribed treatment or diagnostic procedures….” 22 CCR 79577.

Documentation

“The inmate-patient's record shall include written justification for the application of clinical restraints, note the times of application and removal of restraints and document the inmate-patient's status and the judgment of the physician or clinical psychologist on the necessity for continuation of clinical restraints at a minimum of once every twenty-four (24) hours.” 22 CCR 79801(h).

Alternatives Required

“[S]hall only be used when less restrictive alternative methods are not sufficient to protect the inmate-patient or others from injury, and shall not be used as punishment or as a substitute for more effective programming or for the convenience of staff.” 22 CCR 79801(d).

Primary regulation

9 CCR 1115

Who can order it

“[S]hall be based on a written or verbal order of a psychiatrist or clinical psychologist.  Clinical restraint shall additionally require a physician's or physician's assistant's, or nurse practitioner's written or verbal approval operating under the supervision of a physician.... Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b).

When does an MD have to cosign

Always. “Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b).

Is the presence of an MD required

No. “Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b). “Telephone orders… shall be signed within twenty-four (24) hours.” 9 CCR 1115(b).

Duration of each order

“[S]hall be in force no longer than twenty-four hours.” 22 CCR 79801(e).

How often must they check on patients

“A physician shall complete a medical assessment of an inmate-patient at the earliest opportunity but no later than within twenty-four (24) hours.” 22 CCR 79801(c).  “[S]hall be physically checked at least every fifteen (15) minutes by nursing staff…  Fluids and nourishment shall be provided every two hours, except during sleep… Routine range of motion exercises shall be done for at least ten (10) minutes every two (2) hours.” 9 CCR 1115(g).  “[S]hall be placed… only in an area that is under direct observation of staff.” 9 CCR 1115(j).

Staff training required

Chemical Restraints

Seclusion

Same as restraint. 9 CCR 1115(a). “Removing an inmate-patient… to another unlocked area… shall not be considered clinical seclusion.” 9 CCR 1115(d).

Postural Supports

Documentation

“The inmate-patient's record shall include written justification for the application of clinical restraints, note the times of application and removal of clinical restraints and document the inmate-patient's status and the judgment of the physician or clinical psychologist on the necessity of continuing the order at the approval of a physician on the medical safety of the continuation of restraints at a minimum of once every twenty-four (24) hours.” 9 CCR 1115(h).

Alternatives Required

“[S]hall only be used when less restrictive alternative methods are not sufficient to protect the inmate-patient or others from injury, and shall not be used as punishment or as a substitute for more effective programming or for the convenience of the staff.” 9 CCR 1115(d).

Primary regulation

15 CCR 4040

Who can order it

“An employee may use chemical and mechanical restraints for security purposes in parole and institutional operations.” 15 CCR 4040(a).

When does an MD have to cosign

Not required. 15 CCR 4040(a).

Is the presence of an MD required

Not required. 15 CCR 4040(a).

Duration of each order

“Only reasonable and necessary force shall be used.” 15 CCR 4040(b).

How often must they check on patients

Staff training required

“An employee shall not use chemical or physical restraining devices without proper and adequate training. Training shall include… [l]imitations of use, potential dangers of use, who is authorized to use, the conditions of use, and other practical instructions.” 15 CCR 4037(a)(1).

Chemical Restraints

“An employee may use chemical and mechanical restraints for security purposes in parole and institutional operations.” 15 CCR 4040(a).

Seclusion

Postural Supports

Documentation

Alternatives Required

“An employee shall not use physical force in any form as a disciplinary technique to direct or control a ward, except to restrain him.” 14 CCR 4039. “When transporting a ward, restraining equipment shall be used only when a potential threat exists.... No physical restraints shall be used when a ward is being transported by public carrier, e.g., bus, plane, train, etc. 15 CCR 4040(e) & (f).

Primary regulation

Ed. Code 56523; 5 CCR 3052

Who can order it

“Behavioral intervention plans shall only be implemented by, or be under the supervision of, staff with documented training in behavior analysis, including positive behavioral interventions.” 5 CCR 3052(a)(2). “[T]echniques such as prone containment may be used as an emergency intervention by staff trained in such procedures.…” 5 CCR 3052(i)(4)(B).

When does an MD have to cosign

Is the presence of an MD required

Duration of each order

“No emergency intervention shall be employed for longer than is necessary to contain the behavior.” 5 CCR 3052(i)(3).

Extended duration restraint

“Any situation which requires prolonged use of an emergency intervention shall require staff to seek assistance of the school site administrator or law enforcement agency, as applicable to the situation.” 5 CCR 3052(i)(3).

How often must they check on patients

Staff training required

“Behavioral intervention plans shall only be implemented by, or be under the supervision of, staff with documented training in behavior analysis, including positive behavioral interventions.” 5 CCR 3052(a)(2). “[T]echniques such as prone containment may be used as an emergency intervention by staff trained in such procedures.” 5 CCR 3052(i)(4)(B).

Chemical Restraints

Seclusion

“Emergency interventions may not include… locked seclusion, unless it is in a facility otherwise licensed or permitted by state law to use a locked room.” 5 CCR 3052(i)(4)(A).

Postural Supports

Documentation

“A 'Behavioral Emergency Report' shall immediately be

completed and maintained in the individual's file. “ 5 CCR 3052(i)(5).

Alternatives Required

“Emergency interventions may only be used to control… behavior… which cannot be immediately prevented by a response less restrictive than the temporary application of a technique used to contain the behavior.” 5 CCR 3052(i).  “[O]nly behavioral emergency interventions approved by the special education local planning area may be used.” 5 CCR 3052(i)(2).  “Emergency interventions shall not include… [e]mployment of a device or material or objects which simultaneously immobilize all four extremities, except that techniques such as prone containment may be used as an emergency intervention by staff trained in such procedures.” 5 CCR 3052(i)(4)(B).

Primary regulation

42 CFR 483.358

Who can order it

“[M]ust be a physician, or other licensed practitioner permitted by the state and the facility to order restraint or seclusion and trained in the use of emergency safety interventions.… If the resident's treatment team physician is available, only he or she can order….” 42 CFR 483.358(a) & (b).

“If the order…is verbal, the verbal order must be received by a registered nurse or other licensed staff such as a licensed practical nurse while the emergency safety intervention is being initiated or immediately after the emergency safety situation ends." 42 CFR 483.358(d).

When does an MD have to cosign

“The physician or other licensed practitioner… must verify the verbal order in a signed written form and sign the restraint or seclusion order in the resident’s record as soon as possible.  42 CFR 483.358(d) & (j).

Is the presence of an MD required

“[W]ithin 1 hour of initiation…a physician or other licensed practitioner trained … must conduct a face-to-face assessment….” 42 CFR 483.358(f).

“[In case of a verbal order], the physician or other licensed practitioner… must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention.”  42 CFR 483.358(d).

Duration of each order

“[N]o more than 4 hours for residents ages 18-21, 2 hours for residents ages 9 to 17, and 1 hour for residents under age 9.” 42 CFR 483.358(e)(2).

“If the emergency safety situation continues beyond the time limits of the order, a registered nurse or other licensed staff must immediately contact the ordering physician in order to receive further instructions.” 42 CFR 483.362(b).

How often must they check on patients

Clinical staff trained in the use of emergency safety interventions must be physically present [in or immediately outside the seclusion room], continually assessing and monitoring… the resident [in restraint or seclusion] throughout the duration of the emergency safety intervention. 42 CFR 483.362(a) and 483.364(a).

Video monitoring does not meet this requirement. 42 CFR 483.364(a).

Staff training required

The facility must require staff to have ongoing education, training and demonstrated knowledge of:

-        techniques to identify staff and resident behaviors, events, and environmental factors that may trigger emergency safety situations;

-        the use of nonphysical intervention skills, such as de-escalation, medication conflict resolution, active listening, …

-        the safe use of restraint and… seclusion….

 42 CFR 483.376.

Restraint

Means a “personal restraint,” “mechanical restraint,” or “drug used as a restraint.”  42 CFR 483.352.

Mechanical restraint means any device attached or adjacent to the resident’s body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body.  42 CFR 483.352.

Personal restraint means the application of physical force without the use of any device for the purposes of restraining the free movement of a resident’s body.  42 CFR 483.352.

Chemical Restraints

“Drug used as a restraint means any drug that:

-        is administered to manage a resident’s behavior in a way that reduces the safety risk to the resident or others;

-        has the temporary effect of restricting the resident’s freedom of movement; and

-        is not a standard treatment for the resident’s medical or psychiatric condition.”

42 CFR 483.352.

Seclusion

Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving.  42 CFR 483.352.

Time out means the restriction of a resident for a period of time to a designated area from which the resident is not physically prevented from leaving for the purpose of providing the resident an opportunity to regain self-control.  42 CFR 483.352.

Simultaneous use of seclusion and restraint is prohibited. 42 CFR 483.356(a)(4).

Postural Supports

Documentation

Each order for restraint or seclusion must include:

-        the name of the order physician or other licensed practitioner…;

-        the date & time the order was obtained;

-        the emergency safety intervention ordered, including length of time… authorized for use.

42 CFR 483.358(g).

Must document the intervention in the resident’s record… by the end of the shift in which intervention occurs… or, if continuing across shifts, during which it ends.  42 CFR 483.358(h).

Alternatives required

“[M]ust order the least restrictive emergency safety intervention that is most likely to be effective in resolving the emergency safety situation.” 42 CFR 483.358(c).

Primary regulation

9 CCR 1929

Who can order it

May be used “only with a signed order of a physician or licensed psychologist, except in an emergency.… In such an emergency a child may be placed in physical restraint at the discretion of a registered nurse.” 9 CCR 1929(d)(2).

When does an MD have to cosign

Always. “In [an emergency] a child may be placed in physical restraint at the discretion of a registered nurse. An order shall be received by telephone within sixty (60) minutes of the application… and shall be signed by the prescriber within twenty-four (24) hours.” 9 CCR 1929(d)(2).

Is the presence of an MD required

Duration of each order

“All orders for physical restraint shall become invalid two (2) hours after the restraint or seclusion is initiated for children ages 9 to 17, one (1) hour for children under age 9, and four (4) hours for any special education pupils ages 18 through 21….  If continued physical restraint or seclusion is needed a new order shall be required.” 9 CCR 1929(d)(2)(D).

Time frame on large duration orders

“[P]hysical restraint shall not be allowed for longer than twenty-four (24) hours.” 9 CCR 1929(d)(3).  P.R.N. orders are prohibited. 9 CCR 1929(d)(4).

How often must they check on patients

“[A] child placed in physical restraint shall be checked at a minimum of every fifteen (15) minutes by the licensed nursing staff.” 9 CCR 1929(d)(11). “Vital signs shall be measured at least every half hour, unless otherwise indicated by the prescribing professional.” 9 CCR 1929(d)(11)(A).

Staff training required

“Staff participating in the physical restraint or seclusion of a child shall also participate in a required four (4) hours of bi-annual review.” 9 CCR 1922(b).

Restraint

Chemical Restraints

Seclusion

“Seclusion in either a designated seclusion room with a door which may be held shut to prevent a child's egress by a staff member or by a mechanism which releases upon removal of a staff person's foot and/or hand or in any other room or part of the facility where the child is prevented from physically leaving for any period of time, thus limiting their movement, activities and contact with the other children.” 9 CCR 1929(d)(5)(A).

Postural Supports

Documentation

“Full documentation of the episode leading to the use of physical restraint… shall be entered in the child's facility record.” 9 CCR 1929(d)(2)(B).  “At the time physical restraint is initiated, or as soon as practical, but in every case within one (1) hour, information regarding the child's medical condition... shall be reviewed... and noted in the child's facility record.” 9 CCR 1929(d)(2)(C). “A written record of each check shall be placed in the child's record.” 9 CCR 1929(d)(11).

Alternatives Required

“Physical restraint and seclusion shall be used only when alternative methods are not sufficient to protect the child or others from immediate injury. Physical restraint and seclusion shall not be used as aversive treatment, punishment, as a substitute for more effective programming, or for the convenience of the staff.” 9 CCR 1929(a) & (b).

Primary regulation

9 CCR 784.35

Who can order it

“[S]hall only be used as authorized by the order of a physician or psychologist within the scope of their license.” 9 CCR 784.36(a). “In a clear case of emergency, when a physician or psychologist is not available… [seclusion or restraint may be ordered] at the discretion of a licensed nursing staff. A confirming telephone order from a physician or psychologist must be obtained within one (1) hour of the time of the occurrence.” 9 CCR 784.36(d).

When does an MD have to cosign

Always. “Telephone orders… must be signed and dated within no longer than five days following the date of issue of the order.” 9 CCR 784.36(f).

Is the presence of an MD required

No. “Every four (4) hours, when a person is secluded or retrained the medical directory, a physician, a psychologist, a member of the licensed mental health professional… shall in person assess the client’s clinical condition face-to-face.” 9 CCR 78437(a).

Duration of each order

“Orders for seclusion or restraint shall not exceed 24-hours in duration.” 9 CCR 784.36(a)(2).

How often must they check on patients

“At the time restraint or seclusion is initiated, or as soon as practical, but in every case within one (1) hour, information regarding the client's medical condition... shall be reviewed by an on-duty member of the licensed nursing staff, or the documentation of the reason(s) it was not safe to conduct this evaluation.” 9 CCR 784.36(c).

“Regular observation and assessment… [must occur] at least every 15 minutes.” 9 CCR 784.37(c)(1).  

“Clients... shall be provided... timely and appropriate nursing and medical care... at least once per shift, not to exceed eight (8) hours, or more often if indicated by the client's condition.” 9 CCR 784.37(c)(2).

“Every four (4) hours… the medical director, a physician, a psychologist, a member of the licensed nursing staff or a licensed mental health professional designated by the mental health rehabilitation center director, shall in person ass the client's clinical condition face to face.” 9 CCR 784.37(a).

Staff training required

Chemical Restraints

Seclusion

Same as restraint. 9 CCR 784.35 to 784.38.

Postural Supports

Documentation

“Restraint or seclusion shall not be initiated absent the documentation of a separate justification for each intervention.” 9 CCR 784.35(b). 

“Care provided to a client in restraint or seclusion shall be documented in the client record.” 9 CCR 784.38(a).

Alternatives Required

“Restraint and seclusion shall… only [be used] when there is no less restrictive method to prevent immediate injury to the person or others. Restraint and seclusion shall not be used as punishment or for the convenience of the staff, or as a substitute for less restrictive alternate forms of treatment.” 9 CCR 784.35(a).

Primary regulation

22 CCR 79315

Who can order it

“[S]hall only be used upon a physician's written or verbal order.… Telephone orders shall be received only by authorized personnel.” 22 CCR 79315(c).

When does an MD have to cosign

“Telephone orders…  shall be signed by the prescriber within five days.” 22 CCR 79315(c).

Is the presence of an MD required

No.

Duration of each order

“Orders for physical restraints shall be in force for not longer than 24 hours.” 22 CCR 79315(e). “There shall be no PRN orders… for physical or treatment restraints.” 22 CCR 79315(f).

How often must they check on patients

“[S]hall be checked at least every 15 minutes.”  22 CCR 79315(h). “Patients shall be restrained only in an area that is under direct observation of staff and shall be afforded protection from other patients who may be in the area.” 22 CCR 79315(g).

Staff training required

Restraints

[Physical restraints are not defined]

Treatment restraints shall only be used during medically prescribed treatment or diagnostic procedures.  22 CFR 79315(b).

Chemical Restraints

Seclusion

Postural Supports

“Postural supports are devices used to assist the patient in achieving proper body position and balance and… shall include only the following: soft ties; seat belts; spring release trays; cloth vests.  Postural supports are not considered to be restraints and shall only be used to improve the patient's mobility and independent functioning rather than to restrict the patient's movement.” 22 CCR 79317.

Documentation

“Telephone orders… shall be recorded immediately in the patient's health record.” 22 CCR 79315(c). “A written record shall be kept of [required checks] and maintained in the individual patient's health record.”

22 CCR 79315(h).

Alternatives Required

Physical restraints shall only be used as a measure to protect the patient from injury to self or others.  22 CCR 79315(a).

Primary regulation

15 CCR 1358, 1359.  Minimum standards for juvenile facilities set by the Board of Corrections.  Welf. & Inst. Code § 210.

Who can order it

“Minors shall be placed in restraints only with the approval of the facility manager or designee.  The facility manager may delegate authority to place a minor in restraints to a physician.”  15 CCR 1358(c).

When does an MD have to cosign

“A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no later than two hours from the time of placement.  The minor shall be medically cleared for continued retention at least every three hours thereafter.”  15 CCR 1358(c).

Is the presence of an MD required to apply

No.  “A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no later than two hours from the time of placement.  The minor shall be medically cleared for continued retention at least every three hours thereafter. A mental health consultation shall be secured as soon as possible, but in no case longer than four hours from the time of placement, to assess the need for mental health treatment.”  15 CCR 1358(c).

Duration of each order

“Continued retention in restraints shall be reviewed a minimum of every hour.” 15 CCR 1358(c).

How often must they check on patients

“Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and to ensure the safety and well-being of the minor.” 15 CCR 1358(d).

Staff training required

Chemical Restraints

“Minors found by a physician to be a danger to themselves or others by reason of a mental disorder may be involuntarily given psychotropic medication immediately necessary for the preservation of life or the prevention of serious bodily harm, and when there is insufficient time to obtain consent from the parent, guardian, or court before the threatened harm would occur.  It is not necessary for harm to take place or become unavoidable prior to initiating treatment.” 

15 CCR 1439(c).

Seclusion

“Safety Room Procedures.”  “The room shall be used to hold only those minors who present an immediate danger to themselves or others, who exhibit behavior which results in the destruction of property, or reveals the intent to cause self-inflicted physical harm.  A safety room shall not be used for punishment or discipline, or as a substitute for treatment.”  15 CCR 1359.

Postural Supports

Documentation

“Circumstances leading to the application of restraints must be documented.” 15 CCR 1358(b).

“Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and to ensure the safety and well-being of the minor.  Such observation shall be documented at least every 15 minutes.”  15 CCR 1358(d).

Alternatives required

“Physical restraints should be utilized only when it appears less restrictive alternatives would be ineffective in controlling the disordered behavior.  Physical restraints shall be used only for those minors who present an immediate danger to themselves or others, who exhibit behavior which results in the destruction of property, or reveals the intent to cause self-inflicted physical harm.”  15 CCR 1358(b).

Primary regulation

22 CCR 84300

Who can order it

The use of “restraining devices” in group homes is prohibited.  22 CCR 80072(a)(8).  However, “emergency interventions” and the limited use of “postural supports” are permitted.  Emergency intervention plans set out specific limitations on use. 22 CCR 84322.

Mechanical restraints, except postural supports, are prohibited.   22 CCR 84300.1.

Manual restraint for more than 15 consecutive minutes is prohibited unless written approval to continue the restraint after the initial 15 minutes is obtained from the administrator or their designee.  22 CCR 84322(f)(2)(A). After the initial 30 minutes written approval to continue the restraint is obtained from the administrator and facility social work staff.  22 CCR 84322(f)(2)(B).

When does an MD have to cosign

No

Is the presence of an MD required

No

Duration of each order

Manual restraints for more than 15 consecutive minutes in a 24-hour period are prohibited, unless as specified in an emergency intervention plan.  22 CCR 84300.1(a)(11).

Manual restraints for more than 4 cumulative hours in a 24-hour period are prohibited.  22 CCR 84300.1(a)(12).

How often must they check on patients

Pursuant to an emergency intervention plan:

-        Visual check is required after 15 minutes by person other than person restraining child.  22 CCR 84322(f)(2)(A).

-        Visual check is required every 15 minutes after the initial 30 minutes by person other than person restraining child.  22 CCR 84322(f)(2)(C).

Staff training required

“No facility personnel must use emergency intervention techniques on a child unless the training instructor has certified in writing that the facility personnel have successfully completed the [required] emergency intervention training.”  22 CCR 84365(a). 

All facility personnel who will use emergency interventions, must be trained in the appropriate emergency intervention techniques approved to be used by the licensee.  22 CCR 84365.5(b).

Restraint

Mechanical restraint means any physical device or equipment which restricts the movement of the whole or a portion of a child’s body, including… handcuffs, restraining sheets, restraining chairs, leather cuffs and belts or any other similar method.  22 CCR 84001(m)(3).

Manual restraint means the use of a hands-on or other physically applied technique to physically limit the freedom of movement of a child. 22 CCR 84001(m)(1).

Physical restraining device means any physical or mechanical device, material or equipment attached or adjacent to a child’s body which the child cannot remove easily and which restricts the child’s freedom of movement.  22 CCR 84001(p)(1).

Chemical Restraints