The hospital initiates restraint or seclusion based on an individual order.

(1)

The hospital uses restraint or seclusion as ordered by a physician or other authorized licensed practitioner responsible for the patient’s care in accordance with hospital policy and state law and regulation.

(2)

The hospital does not use standing orders or PRN (also known as “as needed”) orders for restraint or seclusion.

(3)

The attending physician is consulted as soon as possible, in accordance with hospital policy, if they did not order the restraint or seclusion. Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (refer to the Glossary).

(4)

Unless state law is more restrictive, orders for the use of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the following time limits: - 4 hours for adults 18 years of age or older - 2 hours for children and adolescents 9 to 17 years of age - 1 hour for children under 9 years of age Orders may be renewed according to the time limits for a maximum of 24 consecutive hours.

(5)

Unless state law is more restrictive, every 24 hours, a physician or other authorized licensed practitioner responsible for the patient’s care sees and evaluates the patient before writing a new order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others, in accordance with hospital policy and law and regulation.

(6)

Orders for restraint used to protect the physical safety of a nonviolent or non-self-destructive patient are renewed in accordance with hospital policy.