Important Facts for Nursing Staff on Restraint Use

Important Facts for Nursing Staff on Restraint Use

? Attempt alternatives to restraints that may be appropriate for the patient and document ? The least restrictive restraints should always be used ? If a nurse trials a patient off of restraints and must place the patient back into restraints, a new order is required ? Restraint type used must match the patient behavior being exhibited and the MD order

? Chemical Restraint:

o Medication(s) are used in doses and/or combinations intended to incapacitate the patient to restrict their freedom of movement AND IS NOT a standard of treatment or dosage for the patient's condition

o Considered restraint for violent behavior o Requires all the same monitoring as restraints for violent behavior, plus continuous patient monitoring x 2

hours (minimum), and vital signs must be obtained q15mins x 3 if the medication is administered via IV or

IM. o Does not include medications administered in standard doses to manage or treat an underlying condition(s)

(e.g. anxiety, psychosis, insomnia).

Restraints for Nonviolent Behavior

Restraints for Violent Behavior

Non-violent/Non-Self Destructive Behavior include

Violent/Self Destructive Behavior include actions by the patient

actions, but not limited to pulling at tubes, lines and which compromises the physical safety of the patient, a staff

medical devices or entangling legs in side rails, or

member or others including but not limited to hitting, kicking,

similar activities with the potential of unintended harm mutilating or other physically aggressive behaviors.

(trauma/injury) to the patient, staff members or others.

Restraint Type: Any device (per VH-Restraint & Seclusion policy) to control nonviolent behaviors. Time-limited:

Restraint Type: Physical holds, Chemical Restraints, Seclusion, and any device (per VH-Restraint & Seclusion policy) to control violent behaviors. Time-limited:

? Must be re-ordered each calendar day

? Adults (18 years or older)- 4 hrs

? Example: If an order is placed at 8AM on

? Children and adolescents (ages 9-17)- 2hrs

4/1/15, a new order is needed by 11:59PM on

? Children (under age of 9)- 1 hrs

4/2/15.

? Orders cannot be "renewed" for restraints Times are pre-determined and must not be

a new order must be placed.

altered

?

PRN or standing orders are prohibited

Orde?r includes:

Order includes:

?1. Type of restraint (must match the type of restraint being applied)

2. Reason for restraint ( behavior) ?3. Duration (default of calendar day per VH policy)

1. Type of restraint (must match the type of restraint being applied)

2. Reason for restraint (behavior) 3. Duration (default to times listed above)

?

If provider is not available:

RN may initiate restraints

?

RN will notify provider within 1 hour

Orders must be re-ordered each calendar day.

Orders must be re-ordered according to defaulted times (listed above).

Regulatory Compliance

Nov 2015, Revised November 2016, Reviewed 9/2017, Revised 1/2018, Reviewed 9/2020

Important Facts for Nursing Staff on Restraint Use

Assess upon initiating restraints:

Assess upon initiating restraints:

? Behavior findings ? Behavioral actions taken ? Behavior outcomes

Document Clinical Justification for restraints every CALENDAR DAY

No 15 minute documentation required

? Behavior findings ? Behavioral actions taken ? Behavior outcomes

Document Clinical Justification for restraints with each NEW Check VS immediatOeRlyDaEfRter implementation

Every 15 minutes, document on each of the following:

Every 2 hours, document on each of the following:

? Readiness for release ? Psychological status ? Physical comfort ? Circulation ? Continuous monitoring ? Type of restraint (start, continued, discontinued)

Every 2 hours, document on each of the following:

? Least restrictive alternative ? Level of distress (rationale for continued use) ? Circulation ? ROM/Positioning ? Fluids ? Food ? Elimination (toileting needs) ? Type of restraint (start, continued, discontinued)

? Vital signs (immediately after application & every 2 hours) ? ROM/Positioning ? Fluids ? Food ? Elimination (toileting needs)

Every shift document on each of the following:

Every shift document on each of the following:

? Plan of Care "Restrain for non-violent reasons" ? Education to patient, family, or patient

representative of necessity and discontinuation criteria for restraint ? Behavior findings ? Behavioral actions taken ? Behavior outcomes

? Plan of Care "Violent restraints/seclusion" ? Education to patient, family, or patient representative of

necessity and discontinuation criteria for restraint ? Behavior findings ? Behavioral actions taken ? Behavior outcomes

Not applicable

Chemical Restraint Monitoring (in addition to above):

Not required for nonviolent restraints

? Continuous monitoring of patient x 2 hours (at a minimum) ? Medication administered via IM or IV push, FOR THE

CONTROL OF VIOLENT BEHAVIOR, vital signs must be obtained every 15 minutes x 3 (at a minimum)

Face to Face Assessment (necessary for all violent orders):

? Conducted by provider within 1 hour of initiation of violent restraints o If provider not available, follow chain of command

? If continued violent restraint orders are needed, a provider must conduct a "face to face" assessment every 24 hours

Regulatory Compliance

Nov 2015, Revised November 2016, Reviewed 9/2017, Revised 1/2018, Reviewed 9/2020

Important Facts for Nursing Staff on Restraint Use

Regulatory Compliance

Nov 2015, Revised November 2016, Reviewed 9/2017, Revised 1/2018, Reviewed 9/2020

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