Seclusion and

RestraintPresented by LSF Health Systems, Northeast and North Central Florida’s Managing Entity

Receiving facilities are governed by

other federal and state laws or

accreditation standards as well as their

own policies and procedures. When in

conflict, whichever applies to a facility

and is most stringent and/or protective

of the person’s rights should be

followed.

December 2014

Learning Objective

To obtain a working knowledge of seclusion and restraint

in order to ensure provider compliance with state

standards and regulations regarding the reporting of

events at state-contracted community substance abuse and

mental health treatment facilities.

Legislative Authority –

Who Must Comply

Crisis Stabilization Units (CSU) and Short-Term Residential Treatment facilities (SRT) licensed under Chapter 394, Part IV, FS. They are also governed by 65E-12, F.A.C.

Any agency licensed under 65D-30.005 (standards for Addiction Receiving Facilities) is also required to adhere to the standards and requirements of 65E-5.180 (7), F.A.C. and, therefore, must report SANDR data.

Additionally, any agency licensed under 65D-30, which exercises control of aggression, is also required to report data.

Source: PAM 155-2 , Chapter 14

Legislative Intent

It is the policy of Florida that the use of seclusion and restraint on

consumers is justified only as an emergency safety measure to be used

in response to imminent danger to the client or others.

THEREFORE, it is the intent of the Florida Legislature to achieve an

ongoing reduction in the use of restraint and seclusion in programs and

facilities serving persons with mental illness.

Baker Act Handbook and User Reference Guide • 2014

State of Florida Department of Children & Families

Definitions

Seclusion

The physical segregation of a person in any fashion or involuntary isolation of a person in a room or area from which the person is prevented from leaving. The prevention may be a physical barrier or by a staffer who is acting in a manner so as to prevent the person from leaving the room or area.

Restraint

A physical device, method or drug used to control behavior. A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the individual’s body so that he or she cannot easily remove the restraint and which restricts freedom of movement or normal access to one’s body.

More Definitions

Seclusion – What it isn’t

Seclusion does not mean

isolation due to a person’s

medical condition or

symptoms.

Restraint – What it isn’t

Restraint does not include physical devices, such as orthopedically prescribed appliances, surgical dressings and bandages, supportive body bands or other physical holding when necessary for routine physical examinations and tests; or for purposes of orthopedic, surgical or other similar medical treatment; when used to provide support for the achievement of functional body position or balance; or when used to protect a person from falling out of bed.

Chemical Restraint

Use of a medication to control the person’s behavior or to restrict his or her freedom of

movement and which is not part of the standard treatment regimen of a person with a

diagnosed mental illness.

• Physically holding a person during a procedure to forcibly administer psychotropic

medication is a physical restraint.

• ETOs (Emergency Treatment Orders) are not the same as chemical restraints.

Consumer Rights

A facility can’t use seclusion/restraint for punishment, to compensate for inadequate staffing or for the convenience of the staff.

Persons have a right to be free from seclusion and restraints, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff.

Consumer Rights

Seclusion or a restraint

can only be used in

emergency conditions,

if needed, to ensure the

consumer’s physical

safety and less

restrictive interventions

have been determined

to be ineffective.

Facilities shall ensure

that all staff are made

aware of these

restrictions on the use

of seclusion/restraint

and shall maintain

records demonstrating

this information has

been conveyed to

individual staff.

Direct Care Staff Training

Staff must be trained as part of orientation (within 30 days) and subsequently

on at least an annual basis. Relevant competency must be demonstrated before

participating in a seclusion/restraint event or related assessment, or before

monitoring/providing care during an event.

Recommended Reading

DCF has adopted rules establishing forms/procedures relating to rights/privileges

of persons seeking mental health treatment from Baker Act facilities.

This training material highlights key standards; please read both operating procedures in full to

gain a thorough understanding of all Seclusion & Restraint requirements

Know Florida’s Guidelines

CFOP 155-20

Use of Seclusion in

Mental Health Treatment

Facilities

Last Revision June 9, 2014

CFOP 155-21

Use of Restraint in

Mental Health Treatment

Facilities

Last Revision Oct. 25, 2012

Standards

Health and safety come first. When a consumer

demonstrates a need for immediate medical attention in

the initiation or course of an event, medical priorities

supersede psychiatric priorities, including the immediate

discontinuation of seclusion or restraint.

Seclusion and restraint will be guided by principles of

trauma-informed care: assessment of traumatic histories

and symptoms; recognition of culture and practices that

are re-traumatizing; processing the impact of an event

with the consumer; and addressing staff training needs to

improve knowledge and sensitivity.

Do’s

Develop and use a Personal Safety Plan for each admission.

Use de-escalation and physical management techniques taught by the facility. Use minimum amount of force necessary when initiating use

of restraints.

Monitor the physical and psychological well-being of the consumer during an event: respiratory and circulatory status, skin integrity, vital signs, specific requirements.

Maintain active certification in CPR for staff members.

Establish and utilize a Seclusion and Restraint Oversight Committee.

Wear gloves, masks or clear face shields for infection control.

Don’ts

Do not use seclusion and restraint simultaneously for people younger than 18 years old.

Do not space yourself farther than arm’s reach from a consumer whose restraints prevent him/her from protective extension of arms when falling.

Do not restrain consumers in a prone position. If prone to prevent imminent serious harm, the consumer will be repositioned to a sitting, standing or supine position as quickly as possible.

Do not place objects over a consumer’s face. Do not secure hands behind the back unless to prevent serious injury.

A Closer

look at the

Personal

Safety Plan

Safety Plan Requirements

The plan will be completed upon admission or as soon as

the consumer is stable enough to complete it with staff

assistance.

The plan will be filed in the consumer’s chart and

reviewed at least every 12 months based on admission

date to determine if changes are necessary.

Review of the personal safety plan will be documented by

the recovery team within 2 working days of a seclusion or

restraint event, and updated if necessary.

All staff will be aware of and have ready access to each

individual’s personal safety plan.

The seclusion and restraint process shall show evidence that the

resident’s choice alternatives, as identified on the personal safety plan

form, have been considered.

Any preference expressed by the consumer regarding the gender of the

observing staff person shall be honored when possible and clinically

appropriate.

Containment, or “take-down”

Sometimes necessary, but must be minimized. DURATION WILL BE ONLY LONG ENOUGH TO GAIN CONTROL. Sitting on top of any part of a consumer during containment is prohibited. The weight of the staff shall be placed to the side of the consumer. Care must be taken not to place any pressure on the individual’s chest, back, lungs, diaphragm or stomach. Nursing staff must be called to assess the resident as soon as possible, within 15 minutes of the restraint and at least every hour thereafter while in restraint.

Initiating ETO (Emergency Treatment Orders)

Seclusion and Restraint can be implemented through an order by a physician or other licensed independent practitioner (ARNP or P.A.), if permitted by facility protocol. Seclusions may be initiated prior to obtaining a written order if the physician is not immediately available. Restraint may be initiated prior to a written order only in an emergency.

Immediate danger

Seclusion or Restraint may be initiated prior to obtaining a written order only if the resident presents an immediate danger to self or others.

An RN or highest level trained staff member who is immediately available may initiate in an emergency.

If someone other than an ARNP or RN initiates restraint, the RN or ARNP will assess the need within 15 minutes of initiation.

A physician/ARNP/RN must conduct a face-to-face exam within 1 hour of initiation. This face-to-face may be delegated to a trained RN.

Seclusion Requirements

Before placing a resident in seclusion, staff shall check the seclusion room to ensure it is safe and free of unsafe items.

Same-gender staff will search the consumer for potentially dangerous objects.

Resident must be clothed appropriately.

The initiating staff person or RN/physician must inform the consumer of the behavior that precipitated the seclusion and explain the behavioral criteria necessary for release. Document release criteria in the physician’s order.

Restraint Requirements

Written order for restraint of residents age 18 and over is limited to 4 hours.

Time limit for residents age 9 through 17 is 2 hours.

Order can be extended up to 4 more hours after review by an ARNP or physician, or by an RN who has physically observed and evaluated the consumer.

Original order may only be extended for a total 24 hours. Then a new order must be written and signed within 24 hours.

After an order has expired, the resident must be seen by a physician, ARNP or PA before a new order can be written. The facility’s administrator must be notified the next business day.

Written orders shall:

Be written on the Order Sheet and included in the resident’s record.

Specify the facts and behaviors justifying the intervention.

Identify the time of initiation and expiration.

Specify the type of intervention.

Include special care or monitoring instructions.

Include the criteria for release.

Specify the type of restraint ordered.

Specify the positioning of the consumer for respiratory and other medical safety considerations.

Specify the physical proximity of the staff member assigned continuous visual observation (i.e. within arm’s length, outside the room)

For both Seclusion and Restraint

…

For Restraint…

Monitoring * A person in restraints must not

be subject to view by other consumers

Observation of a secluded or restrained person must be ongoing with documentation of the resident’s condition made at least every 15 minutes by trained staff. Include behavior, potential injury and respiration.

At least once per hour the observation must be conducted by a nurse.

Staff assigned to monitor must be competent to assess physical and psychological signs of distress.

Consumers must be offered opportunity to drink and to toilet, as requested.

Those in restraints must have range of motion to promote comfort.

Document in chart and log sheet

The emergency situation resulting in the event.

The less restrictive interventions attempted, or the clinical determination that they could not be safely applied.

The name and title of initiating staff member.

Date/time of initiation and release.

Resident’s response to the seclusion or restraint, including the rationale for continued use.

That the resident was informed of the behavior that resulted in seclusion/restraint and the criteria necessary for release.

Release

A consumer shall be released from seclusion or restraint

as soon as he or she no longer appears to present a danger

to themselves or others.

Upon release, a nurse shall observe, evaluate and

document the consumer’s physical and psychological

condition.

After an event, a debriefing process shall take place to

decrease the likelihood of a future event and to provide

support.

Reviewing the event

The individual shall be given the opportunity to process the

event within 24 hours after release.

Each facility will develop policies around this debriefing,

which shall assess the impact of the event on the individual

and help him/her identify and expand coping techniques.

Summary of the review should be placed in medical record.

Staff involved in the event will review it by the close of the

next business day after the event. The recovery team shall meet

and review the consumer’s recovery plan within 2 working

days. Consumer will be invited to participate.

Oversight Committee

Each facility utilizing seclusion and restraint procedures shall establish and gather

an Oversight Committee that includes medical staff to conduct at least weekly

reviews of each use of seclusion or restraint and monitor patterns of use. The

review committee shall include a consumer or external advocate if employed or

whenever possible, and shall employ an analysis and countermeasures approach.

Death Relating to

Seclusion or Restraint

If seclusion or restraint contributed directly or indirectly

to the consumer’s death, DCF must be notified via the

IRAS system within 24 hours of the death, and the

Managing Entity must be called immediately.

Please refer to CFOP 155-20, 155-21 and CFOP 215-6

for specific information on reporting a critical incident.

Technical Assistance

and Monitoring

LSFHS CQI Specialist monitors the reporting of SANDR events at provider facilities, reviewing policies –including those that prohibit the use of SANDR – and offering training where needed. This includes de-escalation techniques.

DCF develops quarterly reports of SANDR data which LSFHS analyzes for frequency, duration and other trends.

LSFHS collaborates with providers on best practices and shares information and success regarding reducing the use of seclusion and restraint.

Reporting SANDR data

Providers will enter SANDR data of

DCF SAMH / LSF-funded

consumers into

https://lsfhealthsystems.org no later

than the 10th following the end of

the reporting month, as per contract.

Providers will enter SANDR data of non DCF/LSF-funded consumers into the SAMHIS web portal no later than the 15th

following the end of the reporting month, per PAM 155-2 Chapter 14.

SANDR

This is the screen where saved SANDR events at provider and M.E. level will show.

To enter an event, click on the link highlighted and follow prompts.

Providers must complete

each entry or the system

will not accept as a valid

event.

Thank you for your attention and review of this important behavioral

healthcare topic. We hope you have found this slide show helpful!