Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING › Article 2 - HOSPITALS › Section R9-10-225 - Psychiatric Services

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				administrator of a hospital that contains an organized psychiatric services
				unit or a special hospital licensed to provide psychiatric services shall
				ensure that in the organized psychiatric unit or special hospital:
1. Psychiatric services are provided under
				the direction of a medical staff member;
2. An inpatient admitted to the organized
				psychiatric services unit or special hospital has a principal diagnosis of a
				mental disorder, a personality disorder, substance abuse, or a significant
				psychological or behavioral response to an identifiable stress or;
3. Except in an emergency, a patient receives
				a nursing assessment before treatment for the patient is initiated;
4. An individual whose medical needs cannot
				be met while the individual is an inpatient in an organized psychiatric
				services unit or a special hospital is not admitted to or is transferred out of
				the organized psychiatric services unit or special hospital;
5. Policies and procedures for the organized
				psychiatric services unit or special hospital are established, documented, and
				implemented that:
a. Establish qualifications
				for medical staff members and personnel members who provide clinical oversight
				to behavioral health technicians;
b. Establish the process for patient
				assessment, including identification of a patient's medical conditions and
				criteria for the on-going monitoring of any identified medical
				condition;
c. Establish the process
				for developing and implementing a patient's care plan including:
i. Obtaining the patient's or the patient's
				representative's participation in the development of the patient's care
				plan;
ii. Ensuring that the patient
				is informed of the modality, frequency, and duration of any treatments that are
				included in the patient's care plan;
iii. Informing the patient that the patient
				has the right to refuse any treatment;
iv. Updating the patient's care plan and
				informing the patient of any changes to the patient's care plan; and
v. Documenting the actions in subsection
				(A)(5)(c)(i) through (iv) in the patient's medical record;
d. Establish the process for warning an
				identified or identifiable individual, as described in A.R.S. §
											36-517.02(B)
				through (C), if a patient communicates to a
				medical staff member or personnel member a threat of imminent serious physical
				harm or death to the individual and the patient has the apparent intent and
				ability to carry out the threat;
e.
				Establish the criteria for determining when an inpatient's absence is
				unauthorized, including whether the inpatient:
i. Was admitted under A.R.S. Title 36,
				Chapter 5, Articles 1, 2, or 3;
ii.
				Is absent against medical advice; or
iii. Is under 18 years of age;
f. Identify each type of restraint
				and seclusion used in the organized psychiatric services unit or special
				hospital and include for each type of restraint and seclusion used:
i. The qualifications of a medical staff
				member or personnel member who can:
(1) Order
				the restraint or seclusion,
(2)
				Place a patient in the restraint or seclusion,
(3) Monitor a patient in the restraint or
				seclusion,
(4) Evaluate a patient's
				physical and psychological well-being after being placed in the restraint or
				seclusion and when released from the restraint or seclusion, or
(5) Renew the order for restraint or
				seclusion;
ii. On-going
				training requirements for a medical staff member or personnel member who has
				direct patient contact while the patient is in a restraint or in seclusion;
				and
iii. Criteria for monitoring
				and assessing a patient including:
(1)
				Frequencies of monitoring and assessment based on a patient's condition,
				cognitive status, situational factors, and risks associated with the specific
				restraint or seclusion;
(2) For the
				renewal of an order for restraint or seclusion, whether an assessment is
				required before the order is renewed and, if an assessment is required, who may
				conduct the assessment;
(3)
				Assessment content, which may include, depending on a patient's condition, the
				patient's vital signs, respiration, circulation, hydration needs, elimination
				needs, level of distress and agitation, mental status, cognitive functioning,
				neurological functioning, and skin integrity;
(4) If a mechanical restraint is used, how
				often the mechanical restraint is monitored or loosened; and
(5) A process for meeting a patient's
				nutritional needs and elimination needs;
g. Establish the criteria and procedures for
				renewing an order for restraint or seclusion;
h. Establish procedures for internal review
				of the use of restraint or seclusion;
i. Establish requirements for notifying the
				parent or guardian of a patient who is under 18 years of age and who is
				restrained or secluded; and
j.
				Establish medical record and personnel record documentation requirements for
				restraint and seclusion, if applicable;
6. If time-out is used in the organized
				psychiatric services unit or special hospital, a time-out:
a. Takes place in an area that is unlocked,
				lighted, quiet, and private;
b.
				Does not take place in the room approved for seclusion by the Department under
				R9-10-104;
c. Is time-limited and does not exceed two
				hours per incident or four hours per day;
d. Does not result in a patient's missing a
				meal if the patient is in time-out at mealtime;
e. Includes monitoring of the patient by a
				medical staff member or personnel member at least once every 15 minutes to
				ensure the patient's health, safety, and welfare and to determine if the
				patient is ready to leave time-out; and
f. Is documented in the patient's medical
				record, to include:
i. The date of the
				time-out,
ii. The reason for the
				time-out,
iii. The duration of the
				time-out, and
iv. The action
				planned and taken to address the reason for the time-out;
7. Restraint or seclusion is:
a. Not used as a means of coercion,
				discipline, convenience, or retaliation;
b. Only used when all of the following
				conditions are met:
i. Except as provided in
				subsection (A)(8), after obtaining an order for the restraint or
				seclusion;
ii. For the management
				of a patient's aggressive, violent, or self-destructive behavior;
iii. When less restrictive interventions have
				been determined to be ineffective; and
iv. To ensure the immediate physical safety
				of the patient, to prevent imminent harm to the patient or another individual,
				or to stop physical harm to another individual; and
c. Discontinued at the earliest possible
				time;
8. If as a result
				of a patient's aggressive, violent, or self-destructive behavior, harm to the
				patient or another individual is imminent or the patient or another individual
				is being physically harmed, a personnel member:
a. May initiate an emergency application of
				restraint or seclusion for the patient before obtaining an order for the
				restraint or seclusion, and
b.
				Obtains an order for the restraint or seclusion of the patient during the
				emergency application of the restraint or seclusion;
9. Restraint or seclusion is:
a. Only ordered by a physician or a
				registered nurse practitioner, and
b. Not written as a standing order or on an
				as-needed basis;
10. An
				order for restraint or seclusion includes:
a.
				The name of the individual ordering the restraint or seclusion;
b. The date and time that the restraint or
				seclusion was ordered;
c. The
				specific restraint or seclusion ordered;
d. If a drug is ordered as a chemical
				restraint, the drug's name, strength, dosage, and route of
				administration;
e. The specific
				criteria for release from restraint or seclusion without an additional order;
				and
f. The maximum duration
				authorized for the restraint or seclusion;
11. An order for restraint or seclusion is
				limited to the duration of the emergency situation and does not exceed:
a. Four continuous hours for a patient who is
				18 years of age or older,
b. Two
				continuous hours for a patient who is between the ages of nine and 17 years of
				age, or
c. One continuous hour for
				a patient who is younger than nine years of age;
12. If restraint and seclusion are used on a
				patient simultaneously, the patient receives continuous:
a. Face-to-face monitoring by a medical staff
				member or personnel member, or
b.
				Video and audio monitoring by a medical staff member or personnel member who is
				in close proximity to the patient;
13. If an order for restraint or seclusion of
				a patient is not provided by a medical practitioner coordinating the patient's
				medical services, the medical practitioner is notified as soon as
				possible;
14. A medical staff
				member or personnel member does not participate in restraint or seclusion,
				monitor a patient during restraint or seclusion, or evaluate a patient after
				restraint or seclusion until the medical staff member or personnel member
				completes education and training that:
a.
				Includes:
i. Techniques to identify medical
				staff member, personnel member, and patient behaviors; events; and
				environmental factors that may trigger circumstances that require restraint or
				seclusion;
ii. The use of
				nonphysical intervention skills, such as de-escalation, mediation, conflict
				resolution, active listening, and verbal and observational methods;
iii. Techniques for identifying the least
				restrictive intervention based on an assessment of the patient's medical or
				behavioral health condition;
iv.
				The safe use of restraint and the safe use of seclusion, including training in
				how to recognize and respond to signs of physical and psychological distress in
				a patient who is restrained or secluded;
v. Clinical identification of specific
				behavioral changes that indicate that the restraint or seclusion is no longer
				necessary;
vi. Monitoring and
				assessing a patient while the patient is in restraint or seclusion according to
				policies and procedures; and
vii.
				Training exercises in which medical staff members and personnel members
				successfully demonstrate the techniques that the medical staff members and
				personnel members have learned for managing emergency situations; and
b. Is provided by individuals
				qualified according to policies and procedures;
15. When a patient is placed in restraint or
				seclusion:
a. The restraint or seclusion is
				conducted according to policies and procedures;
b. The restraint or seclusion is
				proportionate and appropriate to the severity of the patient's behavior and the
				patient's:
i. Chronological and developmental
				age;
ii. Size;
iii. Gender;
iv. Physical condition;
v. Medical condition;
vi. Psychiatric condition; and
vii. Personal history, including any history
				of physical or sexual abuse;
c. The physician or registered nurse
				practitioner who ordered the restraint or seclusion is available for
				consultation throughout the duration of the restraint or seclusion;
d. A patient is monitored and assessed
				according to policies and procedures;
e. A physician or other health professional
				authorized by policies and procedures assesses the patient within one hour
				after the patient is placed in the restraint or seclusion and determines:
i. The patient's current behavior,
ii. The patient's reaction to the restraint
				or seclusion used,
iii. The
				patient's medical and behavioral condition, and
iv. Whether to continue or terminate the
				restraint or seclusion;
f. The patient is given the opportunity:
i. To eat during mealtime, and
ii. To use the toilet; and
g. The restraint or seclusion is
				discontinued at the earliest possible time, regardless of the length of time
				identified in the order;
16. If a patient is placed in seclusion, the
				room used for seclusion:
a. Is approved for
				use as a seclusion room by the Department under
				R9-10-104;
b. Is not used as a patient's bedroom or a
				sleeping area;
c. Allows full view
				of the patient in all areas of the room;
d. Is free of hazards, such as unprotected
				light fixtures or electrical outlets;
e. Contains at least 60 square feet of floor
				space; and
f. Except as provided in
				subsection (A)(17), contains a non-adjustable bed that:
i. Consists of a mattress on a solid platform
				that is:
(1) Constructed of a durable,
				non-hazardous material; and
(2)
				Raised off of the floor;
ii. Does not have wire springs or a storage
				drawer; and
iii. Is securely
				anchored in place;
17. If a room used for seclusion does not
				contain a non-adjustable bed required in subsection (A)(16)(f):
a. A piece of equipment is available for use
				in the room used for seclusion that:
i. Is
				commercially manufactured to safely and humanely restrain a patient's
				body;
ii. Provides support to the
				trunk and head of a patient's body;
iii. Provides restraint to the trunk of a
				patient's body;
iv. Is able to
				restrict movement of a patient's arms, legs, trunk, and head;
v. Allows a patient's body to recline;
				and
vi. Does not inflict harm on a
				patient's body; and
b.
				Documentation of the manufacturer's specifications for the piece of equipment
				in subsection (A)(17)(a) is maintained;
18. A seclusion room may be used for services
				or activities other than seclusion if:
a. A
				sign stating the service or activity scheduled or being provided in the room is
				conspicuously posted outside the room;
b. No permanent equipment other than the bed
				required in subsection (A)(16)(f) is in the room;
c. Policies and procedures are established,
				documented, and implemented that:
i. Delineate
				which services or activities other than seclusion may be provided in the
				room,
ii. List what types of
				equipment or supplies may be placed in the room for the delineated services,
				and
iii. Provide for the prompt
				removal of equipment and supplies from the room before the room is used for
				seclusion; and
d. The
				sign required in subsection (A)(18)(a) and equipment and supplies in the room,
				other than the bed required in subsection (A)(16)(f), are removed before a
				patient is placed in seclusion in the room;
19. A medical staff member or personnel
				member documents the following information in a patient's medical record before
				the end of the shift in which the patient is placed in restraint or seclusion
				or, if the patient's restraint or seclusion does not end during the shift in
				which it began, during the shift in which the patient's restraint or seclusion
				ends:
a. The emergency situation that required
				the patient to be restrained or put in seclusion;
b. The times the patient's restraint or
				seclusion actually began and ended;
c. The time of the face-to-face assessment
				required in subsection (A)(12)(a);
d. The monitoring required in subsection
				(A)(12)(b) or (15)(d), as applicable;
e. The times the patient was given the
				opportunity to eat or use the toilet according to subsection (A)(15)(f);
				and
f. The names of the medical
				staff members and personnel members with direct patient contact while the
				patient was in the restraint or seclusion; and
20. If an emergency situation continues
				beyond the time limit of an order for restraint or seclusion, the order is
				renewed according to policies and procedures.