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

§482.13(e)(3 ) -The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

## Interpretive Guidelines §482.13(e)(3)

Resources are available to assist clinicians in identifying less restrictive restraint or seclusion 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 the field and 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)(3)

- Is there clear documentation in the patient's medical record describing the steps or interventions used prior to the use of the needed restraint or seclusion?  That is, what documentation is in the medical record to explain the rationale for the use of restraint or seclusion?
- Is there documentation that less restrictive measures were tried or considered?
- Is the restraint or seclusion intervention the least restrictive intervention that meets the patient's clinical needs and protects the safety of the patient, staff, or others?
- Did the staff determine that less restrictive alternatives would not meet the patient's clinical needs, or protect the patient's safety or the safety of others?
- Do ongoing documented assessments demonstrate that the restraint or seclusion intervention is needed at this time (or at a time in the past) and that the restraint or seclusion intervention remains the least restrictive way to protect the patient's safety?
- If the time of restraint or seclusion use is lengthy, look for evidence that the symptoms necessitating the use of restraint or seclusion have persisted.  Is there evidence to indicate that the staff have evaluated whether or not the restraint or seclusion can be safely discontinued?

- (i)  in accordance with a written modification to the patient's plan of care.

## Interpretive Guidelines §482.13(e)(4)(i)

The use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint) must be documented in the patient's plan of care or treatment plan.  The use of restraint or seclusion constitutes a change in a patient's plan of care.

The regulation does not require that a modification to the patient's plan of care be made before initiating or obtaining an order for the use of restraint or seclusion.  The use of a restraint or seclusion intervention should be reflected in the patient's plan of care or treatment plan based on an assessment and evaluation of the patient.  The plan of care or treatment plan should be reviewed and updated in writing within a timeframe specified by hospital policy.

## Survey Procedures §482.13(e)(4)(i)

- Determine whether the hospital's procedures are consistent with the requirements of this regulation.  Does the plan of care or treatment reflect a process of assessment, intervention, and evaluation when restraint or seclusion is used?
- Is there evidence of assessment of the identified problem or of an individual patient assessment?
- Does the patient's plan of care reflect that assessment?
- What was the goal of the intervention?
- What was the described intervention?
- Who is responsible for implementation?
- Was the patient informed of the changes in his or her treatment plan or plan of care?
- Did the physician or other LIP write orders that included a time limit?  Were these orders incorporated into the plan of care?
- After the discontinuation of the restraint or seclusion intervention, was this information documented in an update of the plan of care or treatment plan?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "documentation demonstrating consideration and selection of the least restrictive intervention for restraint or seclusion", "trigger_assertion": "restraint or seclusion was applied"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}