Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 1 - RIGHTS OF RECIPIENTS OF MENTAL HEALTH SERVICES › Part B - RIGHTS IN INPATIENT AND RESIDENTIAL SETTINGS › Section 193-1-B-VII - FREEDOM FROM UNNECESSARY SECLUSION AND RESTRAINT

Current through 2024-29, July 17, 2024
A. Seclusion
1. Seclusion means the placement of a
				  recipient alone in an isolation room from which exit is denied.
2. Seclusion may be employed only in the
				  following instances:
a. when absolutely
				  necessary to protect the recipient from causing physical harm to self or
				  others; and
b. to prevent further
				  serious disruption that significantly interferes with other recipients'
				  treatment. Behaviors causing serious disruption that interferes with others'
				  treatment may include uncontrollable screaming, public masturbation, indecent
				  exposure and uncontrolled intrusiveness on other recipients. Use of seclusion
				  may be appropriate in these circumstances if the behaviors cannot be controlled
				  through lesser restrictive means than seclusion and if the behaviors will
				  likely be controlled with the use of seclusion. Seclusion may not be used
				  solely to address the comfort, convenience or anxiety of staff; to address
				  factors related to ward or unit dynamics; to control a recipient's mild
				  obnoxiousness, rudeness, obstinacy, use of profanity or other unpleasantness;
				  nor as discipline for resolved behaviors.
Seclusion under these circumstances shall be employed in
					 the following manner:
i. if the
				  recipient is examined in person by a physician or physician extender to the
				  implementation of seclusion; or
ii.
				  by a registered nurse in telephone consultation with a physician or physician
				  extender.
3.
				  Seclusion may be used only if less restrictive measures are inappropriate or
				  have proven to be ineffective.
4.
				  The decision to place a recipient in seclusion shall be made by a physician or
				  physician extender and shall be entered as a medical order in the recipient's
				  records.
5. All recipients must be
				  examined before being placed in seclusion in accordance with the following:
a. If the physician or physician extender is
				  not immediately available to examine the recipient, the recipient may be placed
				  in seclusion following an examination by a registered nurse if the registered
				  nurse finds that the recipient poses a. risk of imminent harm to self others or
				  following an examination by the nurse and wit telephone consultation from the
				  physician or physician extender in order to prevent further serious disruption
				  that significantly interferes with other recipients' treatment. Any recipient
				  placed in seclusion under these circumstances shall be kept under constant
				  observation while awaiting an examination by a physician or physician
				  extender.
b. The examination by the
				  registered nurse shall be conducted in accordance with a protocol approved by
				  the chief of psychiatry or medicine and by the Director of Nursing. The
				  protocol must include the following:
i. A list
				  of indicators or organic causes of changed behaviors.
ii. Elements for assessment including but not
				  limited to known medical disorders;
a. the
				  recipient's medications including URN administration,
b. mental status, with observation of
				  behavior, speech, affect and suicidal/homicidal ideation;
c. brief neurological examination: pupil size
				  and reactivity, gait, limb movement and strength;
d. vital signs; and
e. cognition using a standard tool.
iii. Provision for completion as
				  soon as is clinically sound, those elements of assessment that require the
				  recipient's cooperation and that the nurse may not be able to perform
				  immediately due to the recipient's condition.
c. A physician or physician extender shall
				  personally evaluate the recipient within 30 minutes after the recipient has
				  been placed in seclusion. If the evaluation does not take place within 30
				  minutes, the reasons for the delay shall be documented in the recipient's
				  record. This provision applies to all recipients, including those placed in
				  seclusion during the night. Any recipient placed in seclusion shall be kept
				  under constant observation while awaiting an examination by a physician or
				  physician extender. The physician examination must be conducted as follows:
i. At Augusta Mental Health Institute the
				  physician or physician extender examination shall be conducted in person in all
				  instances.
ii. At all other
				  facilities, the physician examination may be conducted via telephone
				  consultation with the registered nurse and shall include consideration of the
				  results of the nurse's formal assessment. The physician may order seclusion on
				  the basis of this consultation and shall enter any additional orders for
				  further assessments or treatment as appropriate. Thereafter a physician or
				  physical extender shall examine the recipient in person:
a. within 1 hour when the registered nurse
				  requests that a physician evaluate the recipient in person;
b. within 1 hour when the information is
				  suggestive of organic causes that could lead to harm to the
				  recipient;
c. within 1 hour if the
				  recipient has not had a physical examination during the current hospital stay;
				  and
d. within 12 hours in all other
				  instances.
6. Documentation of the physician or
				  physician extender's examination and, if applicable, the registered nurse's
				  assessment must lie entered in the recipient's file.
7. Staff who place recipients in seclusion
				  shall have documented training in the proper techniques, in less restrictive
				  alternatives to seclusion and in the detection of organic causes of behavioral
				  disturbances.
8. As soon as
				  possible, staff should make reasonable efforts to notify the recipient's
				  parent, guardian or designated representative, if any, that the recipient has
				  been placed in seclusion, and the reasons therefore.
9. Each order for initiation or extension of
				  seclusion shall state the time of entry of the order. It shall state the number
				  of hours the recipient may be secluded, not to exceed ten and the conditions
				  under which the recipient may be sooner released.
10. No PRN orders for seclusion may be
				  written and no treatment plan may include its use as a treatment
				  approach.
11. The need for a
				  recipient's continuation in seclusion shall be re-evaluated every 2 hours by a
				  nurse. The nurse shall examine the recipient in person. This examination may be
				  conducted outside the seclusion room. The nurse shall note the clinical reasons
				  for selection of the examination site. The nurse shall assess the recipient to
				  determine whether he or she continues to pose a danger to self or others, or
				  continues to cause serious disruption of other recipients' treatment (in cases
				  in which an examining physician or physician extender has ordered seclusion for
				  this reason). If the nurse finds danger and that the recipient continues to
				  require seclusion, seclusion may be continued if the physician's or physician
				  extender's order has not yet lapsed. Should the recipient not need continued
				  seclusion, the nurse shall release the recipient even if the time frame of the
				  original order has not yet elapsed.
12. A special progress record/check sheet
				  shall be maintained for each use of seclusion and shall include the following
				  documentation:
a. The indication for use of
				  seclusion, i.e. whether a danger to self, others, or serious disruption of
				  other recipients' treatment;
b. A
				  description of the behaviors that constitute the recipient's danger to self,
				  others, or serious disruption of other recipients' treatment;
c. A description of less restrictive
				  alternatives used or considered, and a description of why these alternatives
				  proved ineffective or why they were deemed inappropriate upon
				  consideration.
13. All
				  orders for the extension of seclusion shall include documentation as for an
				  original order. If the recipient is examined outside of the seclusion room,
				  progress notes shall additionally state where the recipient was examined and
				  the clinical reasons for selecting the site.
14. Every recipient placed in seclusion shall
				  be released, unless clinically contraindicated, at least every two hours to eat
				  drink, bathe, toilet and to meet any special medical orders.
15. Recipients placed in seclusion shall be
				  given maximum observation and in no instance shall they be visually monitored
				  less often than every 15 minutes.
16. A description of the recipient's behavior
				  as observed shall be noted on the progress record/check sheet every 15
				  minutes.
17. The total amount of
				  time that a recipient spends in seclusion may not exceed 24 hours unless:
a. Thee recipient is reassessed in accordance
				  with the protocol described at 5(b) above;
b. The recipient is examined, at Augusta
				  Mental Health Institute, by the director of psychiatry or clinical services
				  and, in other hospitals, by a chief of psychiatry or medicine or his or her
				  physician designee. In cases where the chief or director is the treating
				  physician, he or she shall appoint another physician to conduct hit required
				  examination;
c. The order extending
				  seclusion beyond a total of 24 hours is entered by the director of psychiatry
				  or c1hical services or by the chief of psychiatry or medicine following the
				  examination of the recipient and consultation with the other examiners;
				  and
d. The recipient's guardian or
				  designated representative, if any, and if available, has been
				  notified.
18. Records
				  required by the above provisions shall be a part of the recipient's permanent
				  record. At the mental health institutes, copies shall be forwarded to the
				  medical director, the clinical services director and the recipient advocate. At
				  all other facilities, copies shall be forwarded to the chief of psychiatry or
				  medical services. For a period of one year following adoption of these
				  regulations, these facilities shall submit summaries or copies of reports of
				  each use of seclusion to the Division of Licensing of the Department of
				  Behavioral and Developmental Services. Said reports to DBDS shall be submitted
				  on a quarterly basis, shall not contain information identifying the recipient
				  by name but shall be reported in a manner to permit the reader to discern
				  whether individual recipients have been secluded on repeat occasions.
19. Seclusion may be ordered on the basis of
				  a recipient's self-report, provided the physician extender otherwise verified
				  that the recipient meets the criteria of paragraph 2 above and provided the
				  decision is otherwise clinically appropriate.