N.J. Admin. Code § Tit. 8, ch. 39, app C

Current through Register Vol. 56, No. 21, November 4, 2024

Appendix C

GUIDELINES FOR THE USE OF RESTRAINTS

A. Written policies and procedures for use of restraints should address at least the following:

1. Protocol for the use of alternatives to restraints, such as staff or environmental interventions, structured activities, or behavior management. Alternatives should be utilized whenever possible to avoid the use of restraints;

2. Protocol for the use and documentation of a progressive range of restraining procedures from the least restrictive to the most restrictive;

3. A delineation of indications for use, which should be limited to:

i. Prevention of imminent harm to the resident or other persons when other means of control are not effective or appropriate; or

ii. Prevention of serious disruption of treatment or significant damage to the physical environment;

4. Contraindications for use, which should include, at least, clinical contraindications, convenience of staff, or discipline of the resident;

5. Identification of restraints which may be used in the facility, which should be limited to methods and mechanical devices that are specifically manufactured for the purpose of physical restraint. Locked restraints, double restraints on the same body part, four-point restraints, and confinement in a locked or barricaded room should not be permitted;

6. Protocol for informing the resident and obtaining consent when clinically feasible, and documenting the consent in the resident's record;

7. Protocol for notifying the family or guardian, obtaining consent if the resident is unable to give consent, and documenting the consent in the resident's record; and

8. Protocol for removal of restraints when goals have been accomplished.

B. Procedures for the application of restraints in an emergency should include at least the following:

1. Licensed nursing staff only should initiate the use of emergency restraints;

2. The application of restraints should begin with the least restrictive alternative that is clinically feasible;

3. Emergency restraints should be used only when the safety of the resident or others is endangered, or there is imminent risk that the resident will cause substantial damage to the physical environment;

4. The facility should notify the attending physician or advanced practice nurse or another designated physician and request an order within two hours;

5. The facility should obtain a physician's or advanced practice nurse's order within eight hours;

6. Licensed nursing personnel should evaluate and document the physical and mental condition of the resident in emergency restraints at least every two hours;

7. There should be an assessment of the resident by a registered professional nurse within 24 hours; and

8. Continuation of emergency restraints should occur only upon physician or advanced practice nurse orders, which should be renewed every 24 hours to a maximum of seven days.

C. The facility should continuously attempt to remediate the resident's condition to eliminate or lessen the need for restraints. If the use of restraints is needed beyond one week, at least the following should be done:

1. The need for the continued use of restraints should be implemented only as part of the physician's medical care plan;

2. Every resident in restraints should be assessed by a registered professional nurse at least every 48 hours for the continued use of restraints; and

3. After remediation attempts, there should be an interdisciplinary review of the record of any resident whose assessment indicates the need for continued use of restraints. This review should occur within thirty days of the initiation of the use of restraints.

D. Continuation of the use of restraints beyond 30 days should occur only upon written approval of the committee or its equivalent, and should include at least the following actions:

1. The registered professional nurse should assess the need for continued restraints at least weekly; and

2. An interdisciplinary review should be conducted at least every 30 days to approve the continued use of restraints.

E. The facility should have written policies and procedures to ensure that interventions while a resident is restrained, except as indicated in F below, are performed by nursing personnel in accordance with nursing scope of practice as set forth by the New Jersey Board of Nursing. The policies and procedures should include at least the following:

1. Periodic visual observation, which should be performed with the following frequency:

i. Continuously, if clinically indicated by the resident's condition; or

ii. At least every 15 minutes while the resident's condition is unstable; and thereafter at least every one to two hours, based upon an assessment of the resident's condition.

2. Release of restraints at least once every two hours in order to:

i. Assess circulation;

ii. Perform skin care;

iii. Provide an opportunity for exercise or perform range of motion procedures for a minimum of five minutes per restrained limb and repositioning; and

iv. Assess the need for toileting and assist with toileting or incontinence care.

3. Ensuring adequate fluid intake;

4. Ensuring adequate nutrition through meals at regular intervals, snacks, and assistance with feeding if needed;

5. Assistance with bathing as required at least daily; and

6. Ambulation at least once every two hours, if clinically feasible.

F. The facility should have written policies and procedures for interventions by nursing personnel for residents in restraints for overnight sleeping. These policies and procedures should include at least the following and should be implemented in accordance with nursing scope of practice, as set forth by the New Jersey Board of Nursing;

1. Visual observation based on resident's condition, occurring at least every one to two hours;

2. Administration of fluids as required;

3. Toileting as required;

4. Release of restraints at least once every two hours for repositioning and skin care, if clinically indicated; and

5. Prohibition of any method of restraint which places the resident at clinical risk for circulatory obstruction.

N.J. Admin. Code Tit. 8, ch. 39, app C