Use Of Restraint For Patients And Residents In State Institutions 

Link to law: http://arcweb.sos.state.or.us/pages/rules/oars_300/oar_309/309_112.html
Published: 2015

The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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OREGON HEALTH AUTHORITY,

ADDICTIONS AND MENTAL HEALTH DIVISION: MENTAL HEALTH SERVICES

 

DIVISION 112
USE OF RESTRAINT FOR PATIENTS AND RESIDENTS IN STATE INSTITUTIONS 

309-112-0000
Purpose and Statutory Authority
(1) Purpose. These rules prescribe policies
and procedures concerning the use of restraint in the treatment, and behavior management
of patients in state institutions operated by the Division. In addition to these
general rules, other more specific requirements established by federal regulations
must be followed where applicable.
(2) Statutory Authority.
These rules are authorized by ORS 179.040 and 413.042 and carry out the provisions
of 426.385 and 427.031.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. &
ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert.
ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp),
f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0005
Definitions
As used in these rules:
(1) “Chief Medical
Officer” means the physician designated by the superintendent of each state
institution pursuant to ORS 179.360(1)(f) who is responsible for the administration
of medical treatment at each state institution, or his or her designee.
(2) “Division”
means the State Hospital Division of the Oregon Health Authority.
(3) “Interdisciplinary
Team (IDT)” means a group of professional and direct care staff which has
primary responsibility for the development of a plan for the care and treatment
of an individual patient.
(4) “Patient”
means a person who is receiving care and treatment in a state institution for the
mentally ill.
(5) “Restraint”
means one or more of the following procedures:
(a) “Personal Restraint”
means a procedure in which a patient or resident is placed in a prone or supine
position or held in a chair by another person in order to restrict the physical
movement of the patient or resident;
(b) “Physical Restraint”
means a device which restricts the physical movement of a patient and which cannot
be removed by the person and is not a normal article of clothing, a therapy device,
or a simple safety device; or
(c) “Seclusion”
means the placement of a patient alone in a locked room.
(6) “Restraint Review
Committee” means the committee appointed by the superintendent of each state
institution as provided in OAR 309-112-0030.
(7) “Security Area”
means a cottage or unit in which a program is conducted for dangerous patients,
including those judged guilty except for insanity, those court ordered into a secure
program prior to trial, and those court committed patients not manageable in less
secure programs.
(8) “Security Transportation”
means using physical restraint while a patient is being transported outside a security
area.
(9) “State Institution”
means Oregon State Hospital in Salem and Junction City.
(10) “Superintendent”
means the executive head of the state institution as listed in section (11) of this
rule, or his or her designee.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 11-1982(Temp), f. &
ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84;
MHD 2-1986, f. & ef. 3-31-86; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru
7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert.
ef. 10-21-15 thru 4-15-16
309-112-0010
General Policies Concerning Use of
Restraint
(1) State institutions shall not use
restraint except in emergencies, as provided in OAR 309-112-0015, or as part of
planned treatment programs as provided in 309-112-0017, and only then subject to
the conditions and limitations of these rules. An order for physical restraint may
not be in effect longer than 12 hours. No form of restraint shall be used as punishment,
for the convenience of staff, or as a substitute for activities, treatment, or training.
(3) State institutions shall
provide training in the appropriate use of restraint to all employees having direct
care responsibilities.
(3) Medication will not be
used as a restraint, but will be prescribed and administered according to acceptable
medical, nursing, and pharmaceutical practices.
(4) Patients shall not be
permitted to use restraint on other patients.
(5) Physical restraint must
be used in accordance with sound medical practice to assure the least risk of physical
injury and discomfort. Any patient placed in physical restraint shall be protected
from self-injury and from injury by others.
(6) Checking a patient in
restraint:
(a) A patient in restraint
must be checked at least every 15 minutes;
(b) Attention shall be paid
to the patient’s basic personal needs (such as regular meals, personal hygiene,
and sleep) as well as the person’s need for good body alignment and circulation;
(c) Staff shall document
that the patient was checked and appropriate attention paid to the person’s
needs.
(7) During waking hours the
patient must be exercised for a period not less than 10 minutes during each two
hours of physical restraint. Partial release of physical restraint shall be employed
as necessary to permit motion and exercise without endangering other staff and patients.
(8) Unless the order authorizing
use of restraint specifically provides otherwise, the patient shall be released
as soon as it is reasonable to assume that the behavior causing use of restraint
will not immediately resume if the person is released.
(9) OAR 309-112-0015 and
309-112-0017 require staff of state institutions to apply the most appropriate form
of restraint consistent with the patient’s behavior requiring intervention,
the need to protect the staff and other patients, the patient’s treatment
or training needs and preservation of the patient’s sense of personal dignity
and self-esteem. The determination of the most appropriate intervention requires
consideration of the following factors:
(a) The individual patient
involved; e.g., the present physical ability to engage in violent or destructive
behavior, any preference the individual patient has for one method of behavior management
versus another, and the individual’s reaction to various methods of intervention;
(b) The risk or degree of
physical or psychological harm and discomfort that accompany the various methods
of intervention;
(c) The risk or degree of
interference with the individual’s ongoing treatment or training and other
activities.
(10) A summary of all uses
of restraint, other than personal restraint for 15 minutes or less, shall be sent
to the chief medical officer at least monthly.
(11) The following types
of procedures are part of ordinary and customary medical care for physical illnesses
or conditions and are not subject to the provisions of these rules:
(a) Holding or restraining
a patient during an examination, blood drawing, performance of a diagnostic test
or during treatment for an acute medical condition;
(b) Restricting movement
with orthopedic devices such as casts, wheel chairs, braces, and positioning devices;
(c) Isolating a patient with
a known or suspected infectious disease;
(d) Protecting seizure-prone
and self-abusive patients by the use of protective gear.
(12) A patient, guardian,
or a duly authorized representative of the patient, or guardian has the right to
contest any application of these rules as provided in OAR 309-118-0000 through 309-118-0050
(Grievance Procedures for Use in State Institutions).
(13) Violation of the rights,
policies, and procedures set forth in these rules by an employee of the Division
constitutes cause for disciplinary action.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 11-1982(Temp), f. &
ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84;
MHD 16-1985(Temp), f. & ef. 10-9-85; MHD 2-1986, f. & ef. 3-31-86; MHS 2-2013(Temp),
f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS
6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0015
Use of Restraint in Emergencies
(1) Subject to the provisions of these
rules, restraint may be used to manage the behavior of a patient in emergencies.
An emergency exists, as determined by the chief medical officer or designee if,
because of the behavior of a patient:
(a) There is a substantial
likelihood of immediate physical harm to the patient or others in the institution;
and
(b) There is a substantial
likelihood of significant property damage; or
(c) The patient’s behavior
seriously disrupts the activities of other patients on the unit or cottage; and
(d) Measures other than the
use of restraint are deemed ineffective to manage the behavior.
(2)(a) When an emergency
exists, the staff of a state institution shall select the most appropriate intervention
consistent with OAR 309-112-0010(9);
(b) Whenever the interdisciplinary
team (IDT) has reason to believe that in the course of a patient’s care, custody,
or treatment at a state institution it may become necessary to use restraint in
an emergency, a member of the IDT shall, if practicable, ask the patient for an
expression of preference or aversion to the various forms of intervention. A member
of the IDT shall also ask the parent or guardian for an expression of preference
regarding forms of intervention. The patient’s expression, if any, as well
as that of the parent or guardian shall be relayed to the other IDT members and
recorded in the patient’s chart;
(c) The patient’s wishes
for or against particular forms of intervention shall be respected by the person
authorizing the use of restraint, provided that primary consideration shall be given
to the need to protect the patient and others in the institution.
(3) Authorization:
(a) Except as provided in
subsections (3)(d) and (e) of this rule, restraint shall be administered only pursuant
to the order of the chief medical officer or the chief medical officer’s designee;
(b) For the purposes of this
section, the chief medical officer may designate one or more of the following persons:
A physician licensed to practice medicine in the State of Oregon, a psychologist,
or a psychiatric/mental health nurse practitioner;
(c) The chief medical officer
or designee shall order the use of restraint only after adequately assessing the
patient’s or resident’s condition and the environmental situation;
(d) If the chief medical
officer or designee is not available immediately to assess the need for intervention,
and an emergency exists as defined in section (1) of this rule:
(A) The person in charge
of the unit or cottage at the time:
(i) May authorize temporary
use of restraint for a period of time not to exceed 30 minutes; and
(ii) Shall immediately contact
the chief medical officer or his or her designee.
(B) The chief medical officer
or designee shall personally observe the patient as soon as practicable to assess
the individual and assess the appropriateness of the temporary use of restraint.
The observation shall be documented in the person’s chart.
(e) Every incident of Personal
restraint must be ordered by the chief medical officer or his or her designee, or
as provided in subsection (3)(d) of this rule. The order may be oral or written
but shall be documented as provided in section (4) of this rule.
(4) Documentation:
(a) No later than the end
of their work shifts, the persons who authorized and carried out the use of restraint
shall document in the patient’s chart including but not necessarily limited
to:
(A) The specific behavior
which required intervention;
(B) The method of intervention
used and the patient’s response to the intervention; and
(C) The reason this specific
intervention was used.
(b) Within 24 hours after
the incident resulting in the use of restraint, the chief medical officer or designee
who ordered the intervention shall review and sign the documentation. In the case
of patients detained in a psychiatric hospital pursuant to an emergency hold under
ORS 426.180 through 426.225, the treating physician shall sign the documentation,
if the treating physician is not the chief medical officer or designee who ordered
the intervention.
(5) Time Limits: All orders
authorizing use of restraint shall contain an expiration time, not to exceed 12
hours and consistent with OAR 309-112-0010(8). Upon personal re-examination of the
patient, the chief medical officer or designee may extend the order for up to 12
hours at each review, provided that the behavior of the patient justifies extended
intervention. After each 24 hours of continuous restraint, a second opinion from
another designee of the chief medical officer shall be required for further extension
of the restraint.
(6) Reporting: Under this
rule all emergency uses of restraint in excess of 15 minutes shall be reported daily
to the chief medical officer or designee.
(7) After the second use
of emergency restraint on a particular patient during a one-month period, a treatment
program designed to reduce the need for restraint must be developed.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. &
ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHD 2-1986, f. & ef. 3-31-86;
MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction,
8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0017
Use of Restraint as Part of Planned
Treatment or Training Programs
Subject to the provisions of these rules,
restraint may be used as part of planned treatment program provided the informed
consent of the patient is obtained or, if informed consent cannot be obtained, authorization
to proceed with necessary treatment is obtained as provided in OAR 309-114-0000
through 309-114-0025
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 11-1982(Temp),
f. & ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84,
ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative
correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0020
Use of Security Transportation
The chief medical officer or designee
may authorize the use of secure transportation for patients of a secure program
when outside the security area.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. &
ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert.
ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp),
f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0025
Use of Restraint for Acute Medical
Conditions
(1) During medical treatment for acute
physical conditions, personal and physical restraint may be used to prevent a patient
from injuring himself or herself.
(2) Use of a restraint in
the presence of a physician may be authorized verbally; ongoing or continuing use
of personal or physical restraint must be ordered in writing by a physician.
(3) Treatment staff shall:
(a) Attend to the patient’s
basic personal needs and exercise needs in accordance with general medical practice;
and
(b) To the extent practicable,
accommodate the patient’s mental disabilities treatment and training regimen.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 1-1984, f. 1-20-84,
ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative
correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0030
Restraint Review Committee
(1) Each state institution shall have
a Restraint Review Committee. The members of the committee shall be appointed by
the superintendent of each institution and shall consist of five members; two from
institution staff and three community persons who are knowledgeable in the field
of mental health. A quorum shall consist of three members. The committee may be
one formed specifically for the purposes set forth in this rule, or the duties prescribed
in this rule may be assigned to an existing committee.
(2) The purpose and duty
of the Restraint Review Committee is to review and evaluate at least quarterly the
appropriateness of all such interventions and report its findings to the superintendent.
Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
& 427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 12-1982, f. & ef. 6-10-82; MHD 22-1982(Temp), f. &
ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert.
ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp),
f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16
309-112-0035
Notice to Patients and Employees
(1) Upon admission, state institutions
shall inform patients orally and in writing, of the rights, policies, and procedures
set forth in these rules. In addition, a clear and simple statement of the title
and number of these rules, their general purpose, and instructions on how to obtain
a copy of the rules and how to seek advice about their content shall be prominently
displayed in areas frequented by patients in all state institutions.
(2) All employees of state
institutions shall be notified in writing at the commencement of their employment,
or, for present employees, within a reasonable time of the effective date of these
rules, of the rights, policies, and procedures set forth in these rules.
Stat. Auth.: ORS 179.040
& 413.042
Stats. Implemented: ORS 426.385 &
427.031
Hist.: MHD 1-1982(Temp),
f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 1-1984, f. 1-20-84,
ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative
correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16

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