Section 440 IAC 1.5-3-13 - Requirements and procedures for the use of restraint or seclusionAuthority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4
Affected: IC 12-25
Sec. 13.
The following provisions apply to the use of restraint or seclusion:
(1) A private mental health institution shall have a written plan and written policies in place that shall include the clinical justification for the:(A) use of restraint or seclusion; or(B) simultaneous use of both restraint and seclusion.(2) A facility shall not use restraint or seclusion of any form imposed as a means of: (D) retaliation; by staff. Restraint or seclusion may be imposed only to ensure the immediate physical safety of the consumer, a staff member, or others and must be discontinued at the earliest possible time.(3) Restraint or seclusion may be used only when less restrictive interventions have been determined to be ineffective to protect the consumer, a staff member, or others from harm.(4) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the consumer, a staff member, or others from harm.(5) The use of restraint or seclusion must meet the following requirements: (A) Be in accordance with a written modification to the consumer's plan of care.(B) Be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by the facility's policy and in accordance with state law.(6) The use of restraint or seclusion must be in accordance with the order of a physician or other LIP who is:(A) responsible for the care of the consumer; and(B) authorized to order restraint or seclusion by facility policy and in accordance with state law. An order shall contain behavioral criteria for the consumer's release from restraint or seclusion.(7) An order for the use of restraint or seclusion shall not be written: (A) as a standing order; or(B) on an as needed basis (PRN).(8) The attending physician must be consulted as soon as possible after implementation of the restraint or seclusion if that physician did not order the restraint or seclusion.(9) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the consumer, a staff member, or others may be renewed only in accordance with the following limits for up to a total of twenty-four (24) hours:(A) Four (4) hours for adults eighteen (18) years of age or older.(B) Two (2) hours for children and adolescents nine (9) to seventeen (17) years of age.(C) One (1) hour for children under nine (9) years of age.(10) After the twenty-four (24) hour period described in subdivision (9), and before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other LIP, who is:(A) responsible for the care of the consumer; and(B) authorized to order restraint or seclusion by facility policy and in accordance with state law; must see and assess the consumer.(11) Each order for restraint used to ensure the physical safety of a nonviolent or nonself-destructive consumer may be renewed as authorized by the facility's policy.(12) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. In particular, the use of restraint or seclusion shall be discontinued when the consumer meets the behavioral criteria specified in the order for restraint or seclusion.(13) The condition of the consumer who is restrained or secluded must be monitored by a physician, other LIP, or trained staff that have completed the training criteria specified in subdivision (23) at an interval determined in accordance with the facility's policy.(14) The facility's policy shall specify the training requirements, including the use of restraint or seclusion, for physicians and other LIPs. At a minimum, physicians and other LIPs authorized to order restraint or seclusion by facility policy in accordance with state law must have a working knowledge of the facility's policy regarding the use of restraint or seclusion.(15) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the consumer, a staff member, or others, the consumer must be seen face-to-face within one (1) hour after the initiation of the intervention as follows: (A) By either a: (i) physician or other LIP; or(ii) registered nurse or physician assistant who has been trained in accordance with the requirements specified in subdivision (23).(B) For an evaluation of the following: (i) The consumer's immediate situation. (ii) The consumer's reaction to the intervention.(iii) The consumer's medical and behavioral condition.(iv) The need to continue or terminate the restraint or seclusion.(16) By written policy, a facility may implement requirements that are more restrictive than the requirements contained in subdivision (15)(A).(17) If the face-to-face evaluation specified in subdivision (15) is conducted by a trained registered nurse or physician assistant, the trained registered nurse or physician assistant must consult the attending physician or other LIP who is responsible for the care of the consumer as soon as possible after the completion of the one (1) hour face-to-face evaluation.(18) Staff must assess and monitor a consumer in restraint or seclusion in accordance with the following requirements: (A) Except as provided in clause (C), a consumer placed in restraint or seclusion shall be assessed and monitored continuously through a face-to-face observation by an assigned, trained staff member who has been trained in accordance with the requirements of subdivision (23).(B) If a staff member restrains a consumer by means of physically holding the consumer, another trained staff member shall assess and monitor the restraint continuously through a face-to-face observation.(C) After the first hour, a consumer placed in seclusion or restraint may be monitored by trained staff using video and audio equipment. However, such monitoring must be in close proximity to the consumer.(19) All requirements specified under this subdivision are applicable to the simultaneous use of restraint and seclusion. The use of simultaneous restraint and seclusion is permitted only if the consumer is continually monitored by either of the following:(A) Face-to-face by an assigned, trained staff member.(B) By trained staff using both video and audio equipment, provided, however, that such monitoring must be in close proximity to the consumer.(20) The use of restraint or seclusion must be documented in accordance with the following requirements:(A) When restraint or seclusion is used, the facility shall retain documentation in the consumer's medical record of the following: (i) The one (1) hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of a consumer, a staff member, or others.(ii) A description of the consumer's behavior and the intervention used.(iii) Alternatives or other less restrictive interventions attempted (as applicable).(iv) The consumer's condition, symptom, or symptoms that warranted the use of restraint or seclusion.(v) The consumer's response to the intervention or interventions used, including the rationale for the continued use of the intervention.(B) The consumer's response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the consumer's physical and psychological condition including, but not limited to:(i) respiratory and circulatory status; (iv) any additional special requirements specified in a facility's written policy for the face-to-face assessment; within one (1) hour after the initiation of seclusion or restraint required in subdivision (15).(21) After the termination of an incident of the:(A) use of restraint or seclusion; or(B) simultaneous use of restraint and seclusion; facility staff and the consumer shall participate in debriefing about the intervention.(22) A facility shall collect data regarding each incident of the facility's use of restraint or seclusion in order to monitor and to improve the facility's practices and procedures regarding the use of restraint or seclusion.(23) Facility staff shall be trained in the safe implementation of restraint or seclusion in accordance with the following requirements: (A) Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a consumer in restraint or seclusion at each of the following times:(i) Before performing any of the actions specified in this section.(ii) As part of orientation.(iii) Subsequently on a periodic basis consistent with the facility's policy.(B) The facility must require appropriate staff to have education and training in, and to demonstrate knowledge regarding, the specific needs of the consumer population in the facility in at least the following:(i) Techniques to identify staff and consumer behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion.(ii) The use of nonphysical intervention skills.(iii) Choosing the least restrictive intervention based on an individualized assessment of the consumer's medical or behavioral status or condition.(iv) The safe application and use of all types of restraint or seclusion used in the facility, including training in how to recognize and respond to signs of physical and psychological distress, for example, positional asphyxia.(v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary.(vi) Monitoring the physical and psychological well-being of the consumer who is restrained or secluded, including, but not limited to, the following: (AA) Respiratory and circulatory status.(DD) Any special requirements specified by facility policy associated with the one (1) hour face-to-face evaluation. (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.(C) Individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address consumers' behaviors.(D) The facility must document in staff personnel records that the training and the demonstration of competency were successfully completed.(24) A private mental health institution shall report a death associated with the use of seclusion or restraint to the division in accordance with the following provisions:(A) The facility shall make a verbal report to the division within twenty-four (24) hours of the facility's knowledge of the occurrence of any of the following: (i) Each death that occurs while a consumer is in restraint or seclusion.(ii) Each death that occurs within twenty-four (24) hours after a consumer has been removed from restraint or seclusion.(iii) Each death known to the facility that occurs within one (1) week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a consumer's death. For purposes of this item, "reasonable to assume" includes, but is not limited to, deaths related to: (AA) restrictions of movement for prolonged periods of time;(CC) restriction of breathing; or(B) In addition, a facility shall submit to the division a written report of any occurrence listed in clause (A) within ten (10) working days of the facility's knowledge of the occurrence.(25) Staff shall document in the consumer's medical record the date and time when a consumer's death was reported to the division.(26) A facility shall comply with all requirements of federal laws regarding the: (A) use of restraint or seclusion; and(B) simultaneous use of restraint and seclusion.Division of Mental Health and Addiction; 440 IAC 1.5-3-13; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119-IR-440080742RFA; Readopted filed 8/11/2014, 11:21 a.m.: 20140910-IR-440140240RFAReadopted filed 11/9/2020, 3:09 p.m.: 20201209-IR-440200502RFA