Chapter XII.
SECLUSION AND RESTRAINT
All persons with mental illness have a right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse or neglect (Cal. Welf. & Inst. Code § 5325.1(c)).
A. Defining Seclusion
Seclusion is the involuntary isolation of a patient in a locked room or other limited part of the facility. Seclusion limits the patient's movement and activities as well as contact with other patients. (9 C.C.R. § 865.4(a), 22 C.C.R. § 77029). (For provisions relating to other licensing categories see 22 C.C.R. §§ 72000, 73000, 77000 et. seq).
B. Defining Restraint
Restraint is the physical limitation of movement of a patient by the use of restraining devices, including belts, cuffs, straps, and ties. (22 C.C.R. § 70059, 22 C.C.R. § 71055).
While in restraints, a patient is often in a private room with devices applied at the wrists, ankles and around the waist to hold the patient to a bed (called five point restraints). Sometimes the belt around the waist is not used (four point restraints) and sometimes only the wrists are restrained (two point restraints).C. Authorized Facilities
Seclusion and restraint may only be used in facilities authorized by regulation to use the intervention, under circumstances and in the manner authorized by regulation. Seclusion and restraint requires a physician's order.
D. Legal Criteria
A patient may be secluded and/or restrained only when the patient's behavior poses a serious threat of injury to self or others. The patient must be released as soon as that threat of injury no longer exists.
1. Seclusion and/or restraint may only be used when alternative methods are not sufficient to protect the patient or others from injury. (22 C.C.R. § 71545, 9 C.C.R. § 865.2(a)).
2. Seclusion and/or restraint shall never be used as punishment or as a substitute for a less restrictive alternative form of treatment. (9 C.C.R. § 865.4(a)).
3. Seclusion and/or restraint may only be used for as long as it its necessary to protect the patient or others from injury and there is no less restrictive ways of protecting against such injury. (9 C.C.R. §§ 865.4(a), 865.5).
The law views seclusion and restraint as serious intrusions on individual freedom. A patient may be secluded or restrained only for a demonstrable danger to self or others. It is not proper to seclude and/or restrain a patient for being unmanageable, unresponsive, hyperverbal, or for violating a behavioral contract, absent tangible evidence of the need to protect the patient or others from injury. Finally, seclusion and/or restraint may not be used coercively or as a means of facilitating treatment.
The patient must be released as soon as the threat to self or others is no longer present. Seclusion and/or restraint are not to be used coercively or as a means of facilitating treatment. A patient may not be kept in seclusion pending his development of an "understanding", an "improvement", or an ability to make a behavioral contract with his/her therapist.
"Time-out." Locked seclusion is not a proper penalty for violating the conditions of a "time-out" (the voluntary use of an unlocked room by the patient), if the reason for placing the patient in "time-out" would not have justified placing them in locked seclusion. Leaving an unlocked room in violation of an agreement does not in itself demonstrate a serious danger to self or others and thus does not, in itself, justify locked seclusion since seclusion may not be used as punishment or for convenience of staff; punishing a patient for leaving of a "time-out" room involves both.
E. Documentation
1. Physician’s order
. Seclusion and/or restraint may be imposed only upon written order of a physician, or in a legally defined emergency, by a registered nurse with a physician order shortly thereafter.Proper documentation is the only way to demonstrate and provide a record that the legal criteria for seclusion/restraint has been met. A notation in the chart that a patient was secluded/restrained for being "threatening" or "verbally abusive" does not document good cause. Such a description does not provide the nature of the threat and whether it is sufficiently serious and related to a real risk of injury. The following information must appear in the medical record in order to initiate and continue seclusion/restraint:
• A signed physician's order specifying date, time, type of seclusion/restraint, reasons for seclusion/restraint and specific criteria for release.
• A description of the specific behavior justifying seclusion/restraint. The patient's actions which pose a threat of injury to the patient or others must be included.
• A description of the alternative methods of resolving the behavior attempted or considered by staff prior to the use of seclusion/restraint.
• A description of the continuing behavior which poses a threat to the patient or others, less restrictive interventions attempted and the patient's response to them.
• A description of events during seclusion/restraint: nursing/medical assessments, nursing/medical care, patient/staff interactions, and separate justification for emergency medication and denials of patients' rights.
PRN ("as needed") orders are not appropriate for seclusion and/or restraint. The statutes and regulations require physicians to personally order seclusion and/or restraint after determining that good cause exists in each individual case. Obviously, a PRN order cannot take into consideration whether good cause exists in advance for an unforeseen situation. Furthermore, the physician may not delegate his responsibility in the form of a PRN order.
Finally, all rights denied while the patient is in seclusion and/or restraint shall also be documented in the patient record, including date, time and good cause for denial. (9 C.C.R. §§ 865.3, 865.4(c)).
2. Common Documentation Problems
Advocates should emphasize to physicians and staff that documentation must be specific and factually descriptive. Good documentation states what the patient did and said. Good documentation sets forth the patient's behavior, not the conclusions about the behavior. If the patient picked up something as if to throw it, the documentation in the medical record should state: "Patient attempted to throw wastebasket at staff." Although such behavior could be characterized as `dangerous', `threatening' and `combative', such language is inadequate because it does not describe the actual behavior.
Patient behavior must meet legal criteria. Documentation must show that seclusion/restraint was necessary to prevent injury to the patient and others and that less restrictive interventions were inadequate to control the behavior.
Inadequate Documentation Adequate Documentation
DS/DO, uncommunicative, refuses meds. Pt. refuses to respond to staff, banging head on wall. Struck out at staff when offered meds. Placed in seclusion.
Patient agitated, nonre-directable Pt. won't stop shrieking, physically menacing other pts., intruding into other pts. rooms (4x) after pm medication. Secluded. Started to throw self/staff against wall. 4 pts. until calm.
Threatening, won't respond to limits Patient yelling, pacing all morning. Asked to quiet down, 1:1 for half hour, pt. didn't calm down. Time-out offered, refused. Pt. started threatening to `hurt anyone who comes near me'. Refused prn. Pt. secluded.
F. Appropriate Nursing Care
Regular observation
. Patients in seclusion and/or restraint shall be observed by clinical staff no less than once every fifteen minutes. (22 C.C.R. §§ 70577(j)(3), 71545(c)).
Easy removal. Restraints shall be easily removable in the event of fire or other emergency. (22 C.C.R. §§ 70577(j)(4)), 71545(d)).
Clinical standards for nursing care are more comprehensive. Generally, they require regular assessment for medical condition, toileting, washing, provision of fluids and range of motion exercises. (See attachment ___).
G. Necessary Advisements
Patients shall be informed of all denials of their rights, including seclusion and/or restraint, and the reasons therefore. (9, C.C.R. § 865.3(b)). Such advisement shall include a discussion of criteria the patient must meet for release and the method of assessment for release.
H. Advocate’s Role
A patients’ rights advocate has the duty to: 1) protect the rights of mental health clients with regard to the use of seclusion and/or restraint; 2) protect the mental health client from indiscriminate and punitive incidents of seclusion and/or restraint; and 3) ensure that the documentation of incidents of seclusion and/or restraint required by regulation are maintained.
Avoiding seclusion/restraint. Advocates can counsel clients through training, community meetings and individual consultations on ways to avoid seclusion and/or restraint.
Advocates can counsel clients:
• to avoid threatening (or the appearance of threatening) any type of injury to themselves or others.
• to avoid confrontation (or the appearance of confrontation) with staff.
• to try to tell how they feel and ask for help in calming down if they feel upset.
• if they find themselves in a situation where staff is warning them about their behavior, to attempt to talk to staff about what will help them feel calmer and negotiate for that.
Release from seclusion/restraint. Advocates can facilitate the release of a patient from seclusion and/or restraint through staff education and advising the client. Advocates should make sure staff explains to the client the behaviors that led to placement in seclusion and/or restraint and what the client must do in order to be released from seclusion and/or restraint. Advocates should encourage the client to ask for what they need to regain control and to communicate clearly and calmly to staff that they will not cause injury to themselves or others.
