Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.13(e)(2) - Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.

## Interpretive Guidelines §482.13(e)(2)

A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint or seclusion is outweighed by the risk of not using the restraint or seclusion.  Less restrictive interventions do not always need to be tried, but less restrictive interventions must be determined by staff to be ineffective to protect the patient or others from harm prior to the introduction of more restrictive measures.  Alternatives attempted or the rationale for not using alternatives must be documented.

The underpinning of this regulation is the concept that safe patient care hinges on looking at the patient as an individual and assessing the patient's condition, needs, strengths, weaknesses, and preferences.  Such an approach relies on caregivers who are skilled in individualized assessment and in tailoring interventions to the individual patient's needs after weighing factors such as the patient's condition, behaviors, history, and environmental factors.

Resources are available to assist clinicians in identifying less restrictive interventions.  For example, the American Psychiatric Association (APA), American Psychiatric Nurses Association (APNA), and the National Association of Psychiatric Health Systems (NAPHS), with support from the American Hospital Association (AHA), have sponsored the publication of a document entitled, 'Learning from Each Other-Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health.'  This document, published in 2003, was developed through dialogue with clinicians in the field and included extensive input from behavioral healthcare providers throughout the country who have been working to reduce the use of restraint and seclusion and to improve care within their facilities.  To access this document and other useful resources, visit the web sites of the sponsoring organizations:  http://www.naphs.org; http://www.psych.org; http://www.apna.org; http://www.aha.org.

## Survey Procedures §482.13(e)(2)

- Do physician's or other LIP's orders specify the reason for restraint or seclusion, the type of restraint, and the duration of restraint or seclusion?
- Does the severity of the behavior justify seclusion or restraint usage by identifying an immediate and serious danger to the physical safety of the patient or others?
- Is there evidence that the hospital considers factors other than the individual patient in determining causes for the need for restraints or seclusion (i.e., environmental factors)?
- Does the medical record include documentation of an individual patient assessment and a revision of the plan of care?
- Does the medical record reflect changes in behavior and staff concerns regarding safety

risks to the patient, staff, or others prompting use of seclusion or restraints?

- Did the patient's behavior place the patient or others at risk for harm? Was the patient's behavior violent or self-destructive?
- Were other, less restrictive interventions tried and documented, or is there evidence that alternatives were considered and determined to be insufficient?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "documentation of determination that less restrictive interventions were ineffective", "trigger_assertion": "use of restraint or seclusion"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}