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

§482.13(e)(15) - All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion.  Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored -

- (i) Face-to-face by an assigned, trained staff member; or
- (ii) By trained staff using both video and audio equipment.  This monitoring must be in close proximity to the patient.

## Interpretive Guidelines §482.13(e)(15)

When the simultaneous use of restraint and seclusion is employed, there must be adequate documentation that justifies the decision for simultaneous use as well as vigilance in continuously monitoring the patient so that the patient's care needs are met.

All requirements specified under standard (e) apply to the simultaneous use of restraint and seclusion.  The simultaneous use of restraint and seclusion is not permitted unless the patient is continually monitored by trained staff, either through face-to-face observation or through the use of both video and audio equipment.  Monitoring with video and audio equipment further requires that staff perform the monitoring in close proximity to the patient.  For the purposes of this requirement, 'continually' means ongoing without interruption.  The use of video and audio equipment does not eliminate the need for frequent monitoring and assessment of the patient.

An individual who is physically restrained alone in his or her room is not necessarily being simultaneously secluded.  The individual's privacy and dignity should be protected to the extent possible during any intervention.  In fact, the purpose of restraining a patient alone in his or her room may be to promote privacy and dignity versus simultaneously using seclusion and restraint.  While this distinction may be difficult to make, it is helpful to consider whether the patient would, in the absence of the physical restraint, be able to voluntarily leave the room.  If so, then the patient is not also being secluded.  However, if the physical restraint was removed and the patient was still unable to leave the room because the door was locked or staff were otherwise physically preventing the patient from doing so, then the patient is also being secluded.

Staff must take extra care to protect the safety of the patient when interventions that are more restrictive are used.  Monitoring must be appropriate to the intervention chosen, so that the patient is protected from possible abuse, assault, or self injury during the intervention.

## Survey Procedures §482.13(e)(15):

- Review the hospital's policy regarding simultaneous use of restraint and seclusion to determine whether it provides for continual monitoring and otherwise complies with all requirements of §482.13.
- Conduct document review and staff interviews to determine if practice is consistent with the hospital policy and required uninterrupted audio and visual monitoring is provided as required.
- Is the staff member monitoring the patient with video and audio equipment trained and in close proximity to ensure prompt emergency intervention if a problem arises?
- Does the video equipment cover all areas of the room or location where the patient is restrained or secluded?
- Is the audio and video equipment located in an area that assures patient privacy?
- Is the equipment appropriately maintained and in working condition?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "continual monitoring by trained staff (face-to-face OR via video/audio equipment in close proximity)", "trigger_assertion": "simultaneous use of restraint and seclusion"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}