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THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. GREENVILLE HOSPITAL SYSTEM MANUAL OF POLICY DIRECTIVES POLICY: S-050-02B TITLE: Emergency Use of Restraint and Seclusion to Manage Violent, Self- destructive Behavior DATE: October 1, 2008 (Revised) I. Policy Statement A safe environment is provided for all patients while considering the individual needs for the patient and treating the patient with respect and dignity. It is the intent of GHS to use seclusion/restraint only in emergency situations to ensure the patient’s safety or the safety of others. This policy applies system-wide to the emergency restraint or seclusion of patients for the purpose of managing violent, self-destructive behavior, regardless of the facility in which the patient is being treated. II. Definitions A. Seclusion Seclusion is an emergency intervention necessary for behavior management taken to improve patient well being when less restrictive interventions have been determined to be ineffective. Seclusion is involuntarily confining a patient alone in a room or area where the patient is physically prevented from leaving. B. Restraint for Management of Violent, Self-destructive Behavior An emergency intervention necessary to manage violent, self-destructive behavior that poses a threat to the patient, staff or others. 1. Physical Restraint: any manual method or physical or mechanical device that restricts freedom of movement or normal access to one’s body, material, or equipment, attached or adjacent to the patient’s body that the patient cannot easily remove. Holding a patient in a manner that restricts the patient’s movement constitutes restraint for that patient. THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B 2. Chemical Restraint: a medication used to control violent, self- destructive behavior and is not a standard treatment and/or a standard dose for the patient’s medical or psychiatric condition. The medications that comprise the patient’s regular medical regimen (including PRN medications) and are included in the patient’s plan of care are not considered chemical restraints unless administered in a dose which is larger than the usual ordered dose. 3. Protective Devices: devices used to protect the patient (i.e. bed rails, table top chairs, wheelchairs, braces and other devices used for postural support only), and are not used for behavior management are not considered a restraint. A positioning or securing device used to maintain the position, limit mobility or temporarily immobilize during medical, dental, diagnostic or surgical procedures is not considered a restraint. C. Emergency An emergency situation is defined as one where the patient’s behavior is violent, self-destructive and where the behavior presents an immediate and serious risk of harm to the patient, staff or others. Non-physical interventions are not effective or not viable, and safety issues require an immediate physical response. III. Qualifications of Hospital Personnel A. Only physicians who are licensed in South Carolina may issue an order to restrain a patient. Licensed independent practitioners within the hospital(s) can delegate the ordering of restraints to physician assistants and advanced practice nurses who meet the staff training requirements as outlined in this policy. Licensed independent practitioners who order restraints will have a working knowledge of this policy and of the restraint devices available in the organization. Registered Nurses and Physician’s Assistants who have been specially trained as outlined in this policy may, in consultation with the ordering physician perform the face-to-face evaluation. Registered Nurses and Physician’s Assistants may not perform consecutive face-to-face evaluations on a patient who is to remain restrained or secluded. B. Staff will be trained and competent in the application of restraints, implementation of seclusion, monitoring, assessment, and the provision of care for the patient in restraint or seclusion prior to initiating restraint or 2 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B seclusion and caring for/monitoring patients who are restrained or secluded. C. Staff will be trained during the orientation period and will demonstrate competency yearly. Staff training will include: 1. Techniques to identify staff and patient behaviors, events and environmental factors that may trigger circumstances that require the use of restraint or seclusion. 2. The use of nonphysical intervention skills 3. Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical or behavioral status or condition. 4. The safe application of all types of restraint or seclusion used in the hospital. 5. Recognition of and response to signs of physical and psychological distress. 6. The use of first aid techniques and certification in the use of cardiopulmonary resuscitation with recertification as required. 7. Clinical identification of specific behavioral changes that indicated that restraint or seclusion is no longer necessary. 8. Monitoring physical and psychological well-being of the patient who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, vital signs, intake and output. D. Additional Qualifications and Training for Registered Nurses and Physician’s Assistants who perform the face-to-face evaluation. 1. Non-physician providers who perform the face-to-face evaluation will have completed the initial staff training requirement, have demonstrated competency and will have at least one year of experience working in a psychiatric setting including at least six months working at Marshall Pickens. E. Qualifications of Trainers 3 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B 1. Individuals providing training to staff will have the following qualifications: a. Knowledge of adult training principles. b. A working knowledge of staff training requirements as outlined in this policy and including the hospital’s policies on restraint for nonviolent, non-self destructive patients and for restraint and seclusion for violent, self-destructive patients. c. A working knowledge of restraint devices available within the hospital system. IV. Staff Responsibilities A. Alternatives to Seclusion and Restraint The specific clinical setting and professional judgment of qualified staff will be used to determine the appropriate intervention prior to considering seclusion or restraint of the patient for the purpose of behavior management. Non-physical techniques are the preferred intervention in the management of patient behavior. The following descriptions are provided to illustrate examples of alternative non-physical interventions that may be considered prior to seclusion or restraint. 1. Verbal instruction/re-direction 2. Close observation/one to one 3. Time out 4. Medication that is part of the patient’s current plan of care. B. Reasons for Seclusion or Restraint 1. The decision to use seclusion or restraint for violent self-destructive behavior is driven by comprehensive individual assessment that concludes that for this patient, at this time, the use of less intrusive measures poses a greater risk than the risk of using seclusion or restraint. 2. The least restrictive form of restraint will be used for the patient with consideration of the patient’s age, development stage, physical condition, mental condition and demonstrated behavior. 4 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B C. Physician Order Required Initiation of seclusion or application of restraint requires a physician order that: 1. Specifies a start and an end time. 2. Is time limited to a maximum of: 4 hours for individuals 18 years old or older, 2 hours for children and adolescents 9 years to 17 years old, and 1 hour for children under 9 years old. 3. Is behavior specific, i.e., addresses the specific patient behavior that indicates the need for seclusion or behavioral management restraint is clinically justified? 4. Is written for a specific episode – NEITHER PRN NOR STANDING ORDERS ARE PERMITTED. 5. Identifies the type of seclusion or behavioral management restraint(s) to be initiated, beginning with the least restrictive type of seclusion or behavioral restraint appropriate under the circumstances. 6. Telephone orders must be dated, timed, and authenticated by the ordering physician (or any practitioner responsible for care of the patient) within 24 hours of the time the restraint was initiated. Staff will document all elements of the physician’s verbal or telephone order in the patient’s progress notes. If a patient has been in seclusion only and a qualified staff member determines that the patient requires seclusion AND restraint, a new physician’s order must be obtained for restraints and the patient must be continuously monitored by a qualified staff member who is in the room or in close proximity using video equipment. A physician face to face evaluation must occur within an hour of each new order. IF THE ORIGINAL ORDER END TIME HAS EXPIRED OR THE PATIENT HAS BEEN RELEASED FROM RESTRAINTS, OR THERE IS A NEW REASON FOR THE USE OF RESTRAINT, A NEW ORDER IS REQUIRED. D. Seclusion/Restraint Prior to Order for Violent, Self-Destructive Behavior 5 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B A patient may be secluded or restrained for before a physician order is obtained if in the professional judgment of qualified staff, seclusion or restraint is clinically indicated to prevent imminent injury to the patient or others. 1. IN SUCH AN EVENT A PHYSICIAN’S ORDER MUST BE OBTAINED AS SOON AS POSSIBLE BUT NO LONGER THAN ONE HOUR FROM THE TIME SECLUSION OR RESTRAINT BEGAN. 2. If the restraint/seclusion for violent, self-destructive behavior is initiated by qualified staff, the treating physician is called within one hour to provide a verbal or written order for the continuation of the seclusion or behavioral management restraint. 3. The “treating physician” is the physician who is responsible for the management and care of the patient. If the “treating physician” is unavailable, another physician may be called. E. Face to Face Evaluation A FACE TO FACE EVALUATION of the patient WITHIN ONE HOUR of the initiation of seclusion/restraint by the ordering physician. If the ordering physician is not available on site, the FACE TO FACE EVALUATION may be performed by a specially trained registered nurse or physician’s assistant in consultation with the treating physician. The purpose of the face to face evaluation is to assess the patient’s response to restraint, assist the patient and staff to identify ways to help the patient regain control, to make any necessary revisions to the patient’s plan of care and to revise orders as appropriate. 1. When the treating physician is unavailable, a specially trained RN or physicians assistant may perform the face to face evaluation or the RN will notify another physician to perform the face to face evaluation. 2. If the patient is in the seclusion room, the physician or specially trained registered nurse or physicians assistant will enter the seclusion room to perform the face to face evaluation. When the patient is out of control or considered a threat to others, the physician or other staff member performing the face to face may observe through a window or by video camera. 6 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B 3. If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician or other specially trained staff member arrives to perform the assessment, the face to face evaluation will be performed within one hour after the initiation of intervention. 4. The face to face evaluation is documented on the progress notes. F. Re-evaluation and Continuation of Seclusion/Restraint The use of restraint/seclusion to control violent, self-destructive behavior must be limited to the duration of the emergency safety situation regardless of the length of the order. 1. Reassessment and re-evaluation for the need for continuation of seclusion/restraint must be done by an RN every 4 hours for patients 18 years old or older, every 2 hours for ages 9 to 17 years and every one hour for children younger than 9 years old. At that time the RN will re- evaluate the efficacy of the current plan of care and will work with the patient to identify ways to help him regain control. 2. The RN may discontinue restraint or seclusion of the patient at any time the RN determines there is no longer an emergency safety situation, regardless of the length of the order. 3. The RN may contact the physician with a recommendation to renew the order and continue the behavioral restraint or seclusion and the physician may issue a verbal renewal, so long as the order, including all renewals, is consistent with the maximum time limitations set forth above. If the previous face to face evaluation was performed by a specially trained registered nurse or physicians assistant, the physician must perform the face to face evaluation within one hour of the renewal of the order. 4. The RN will document the need for continuation of seclusion/restraint in the patient progress notes. 5. If a patient remains in seclusion or behavioral management restraint continuously for 8 hours or longer or has 2 episodes in 8 hours a physician must perform an in person re- 7 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B evaluation at least every 8 hours for adults, 18 years or older, and every 4 hours for children 17 years or younger. G. Periodic Assessment and Assistance 1. Staff who are trained in methods to minimize the use of restraint and/or seclusion and in the safe use of restraint and/or seclusion assess the individual at the initiation of restraint and/or seclusion and every 15 minutes thereafter. 2. This assessment includes, as appropriate to the type of restraint or seclusion employed:  signs of injury associated with the application of restraint or seclusion  nutrition/hydration  circulation and range of motion in the extremities  vital signs  respiratory and cardiac status  hygiene and elimination  physical and psychological status and comfort  readiness for discontinuation of restraint or seclusion Documentation will occur on the behavioral management restraint/seclusion flow sheet. 3. Staff provide assistance to individuals in understanding the reason for the restraint or seclusion and in meeting behavior criteria for the discontinuation of restraint or seclusion. H. Continuous Monitoring The patient who is secluded and restrained must be monitored continuously by a qualified staff member, either in person or through an observation window, for the first hour. After the first hour, the patient may be monitored, or watched continuously, by a qualified staff member 8 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B through an audio-visual system. A secluded and restrained patient must be monitored person to person throughout the entire time of restraints. If the patient is in a physical hold, a second qualified staff person is assigned to observe the patient and staff member holding the patient. I. Discontinuation of Seclusion/Restraint The patient will be released as soon as possible from seclusion/restraint if, in the professional judgment of qualified staff, the behavior that required seclusion/restraint has changed and the patient no longer requires seclusion/restraint for safety. All time limits in physician orders for behavioral management restraints or seclusion are maximums, and will not prohibit qualified staff from discontinuing the restraint or seclusion sooner than the expiration of such time limits. V. Documentation A. All verbal or telephone physician’s orders will be written on the Physician’s Order Sheet, dated, timed and signed by the physician (or by a physician having coverage responsibility on behalf of the ordering physician) within 24 hours of the time the restraint was initiated (no later than the next calendar day). An example of an appropriate order for a child is as follows: Seclude patient for one hour for excessive aggressive, destructive behavior. B. Initial entry on the seclusion/restraint form or patient progress notes should include circumstances of why the patient is in need of seclusion/restraint, and that less restrictive interventions have been attempted and were ineffective or were not viable. The progress notes will include the rationale for the type of physical intervention selected, notification of the patient’s family (where appropriate), the behavior criteria identified for discontinuation of the restraint or seclusion, and that the patient has been informed of these criteria. C. The physician’s face to face evaluation of the patient will be documented in the progress notes. The RN’s periodic re-evaluations will be documented in the progress notes, including any assistance provided to the patient to help him meet the behavior criteria for discontinuation of the restraint or seclusion. 9 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B D. All periodic assessment monitoring will be documented in the behavioral management restraint/seclusion flow sheet. VI. Clinical Leadership Notification Clinical Leadership is defined as the Charge Nurse and the Unit-specific chain of command. Hospital Clinical Leadership will be informed if a patient is secluded/restrained 2 or more times in a 12 hour period, or if a patient remains in seclusion for more than 12 hours. Thereafter Clinical Leadership is notified every 24 hours if the patient remains in restraint or seclusion for violent, self-destructive behavior. Clinical Leadership will also be notified immediately of patient injuries or deaths resulting from or during behavioral restraint or seclusion. Clinical leadership will immediately notify the Quality Management Department. Clinical Leadership is defined as the Charge Nurse and the Unit-specific chain of command. VII. Reporting Requirements External reporting of injury or death while in restraint or seclusion will be made by Quality Management. A. The staff member who provides care to a patient who is injured or dies while in restraint or seclusion will immediately notify the manager, administrator-on-call or Nursing Administrative Supervisor on duty. B. The manager, administrator-on-call or Nursing Administrative Supervisor on duty will immediately notify Quality Management. C. An investigation will be conducted by the Director of Quality Management or designee and the Chair of the Falls/Restraint Committee. D. A report of injury or death while in restraint or seclusion, or attributed to restraint or seclusion will be made by telephone and fax to the CMS regional office no later than the close of business the next business day after the death has occurred. E. The date and time the injury or death was reported to CMS will be documented in the patient’s medical record by the Director of Quality Management or designee. 10 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

THIS POLICY HAS BEEN REISSUED SINCE JULY 2004. Emergency Use of Restraint and Seclusion to Manage Violent, Self-destructive Behavior S-050-02B VIII. Family Notification and Education As soon as practical the family of the patient will be notified and informed of the need to provide patient safety. The family will not be notified if the patient is an independent adult and chooses to keep the intervention confidential. A. During the admission/orientation process, the patient and/or the patient’s family will be informed of the hospital’s seclusion/restraint policy. B. The issues relating to the seclusion/restraint episode will be addressed in a therapeutic interaction between the patient and a qualified staff member during a debriefing session on the restraint or seclusion episode. IX. Review of Frequent or Prolonged Use of Seclusion/Restraint The care of patients who require frequent or prolonged seclusion or restraint will be reviewed on a periodic basis according to individual service unit Performance Improvement Plans. A. Seclusion and restraint 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 audio and video equipment at a close proximity to the patient. Continuous monitoring is defined as uninterrupted monitoring. B. All staff involved in a behavioral healthcare setting in an episode of seclusion or restraint of a patient for behavioral management reasons will participate in a debriefing conference within 24 hours of the seclusion/restraint episode. The debriefing will include an assessment of what changes could have been made to prevent or handle the situation in a different manner. C. The individual hospitals or service units will collect data on the use of seclusion and restraint in order to monitor and improve high risk practices. 11 THIS INDIVIDUALLY ISSUED AND DISTRIBUTED POLICY DOES NOT CREATE A CONTRACT OF EMPLOYMENT BETEEN THE GHS AND THE EMPLOYEE. EMPLOYMENT AT GHS IS AT WILL. ALL PREVIOUSLY ISSUED VERSIONS OF THIS POLICY ARE HEREBY REVOKED.

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