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The Oregon Administrative Rules contain OARs filed through June 15, 2016
 
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OREGON HEALTH AUTHORITY,
HEALTH SYSTEMS DIVISION: MENTAL HEALTH SERVICES

 

DIVISION 112

USE OF RESTRAINT FOR PATIENTS IN STATE INSTITUTIONS 

309-112-0000

Purpose and Statutory Authority

(1) Purpose. These rules prescribe policies and procedures concerning the use of restraint in the treatment, and behavior management of patients in state institutions operated by the Division. In addition to these general rules, other more specific requirements established by federal regulations must be followed where applicable.

(2) Statutory Authority. These rules are authorized by ORS 179.040 and 413.042 and carry out the provisions of 426.385.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0005

Definitions

As used in these rules:

(1) “Chief Medical Officer” means the physician designated by the superintendent of each state institution pursuant to ORS 179.360(1)(f) who is responsible for the administration of medical treatment at each state institution, or his or her designee.

(2) “Division” means the Division of State Hospitals of the Oregon Health Authority.

(3) “Interdisciplinary Team (IDT)” means a group of professional and direct care staff which has primary responsibility for the development of a plan for the care and treatment of an individual patient.

(4) “Patient” means a person who is receiving care and treatment in a state institution for the mentally ill.

(5) “Restraint” means one or more of the following procedures:

(a) “Personal Restraint” means a procedure in which a patient or resident is placed in a prone or supine position or held in a chair by another person in order to restrict the physical movement of the patient or resident;

(b) “Physical Restraint” means a device which restricts the physical movement of a patient and which cannot be removed by the person and is not a normal article of clothing, a therapy device, or a simple safety device; or

(c) “Seclusion” means the placement of a patient alone in a locked room.

(6) “Restraint Review Committee” means the committee appointed by the superintendent of each state institution as provided in OAR 309-112-0030.

(7) “Security Area” means a cottage or unit in which a program is conducted for dangerous patients, including those judged guilty except for insanity, those court ordered into a secure program prior to trial, and those court committed patients not manageable in less secure programs.

(8) “Security Transportation” means using physical restraint while a patient is being transported outside a security area.

(9) “State Institution” means Oregon State Hospital in Salem and Junction City.

(10) “Superintendent” means the executive head of the state institution as listed in section (11) of this rule, or his or her designee.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 11-1982(Temp), f. & ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHD 2-1986, f. & ef. 3-31-86; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0010

General Policies Concerning Use of Restraint

(1) State institutions shall not use restraint except in emergencies, as provided in OAR 309-112-0015, or as part of planned treatment programs as provided in 309-112-0017, and only then subject to the conditions and limitations of these rules. An order for physical restraint may not be in effect longer than 12 hours. No form of restraint shall be used as punishment, for the convenience of staff, or as a substitute for activities, treatment, or training.

(2) State institutions shall provide training in the appropriate use of restraint to all employees having direct care responsibilities.

(3) Medication will not be used as a restraint, but will be prescribed and administered according to acceptable medical, nursing, and pharmaceutical practices.

(4) Patients shall not be permitted to use restraint on other patients.

(5) Physical restraint must be used in accordance with sound medical practice to assure the least risk of physical injury and discomfort. Any patient placed in physical restraint shall be protected from self-injury and from injury by others.

(7) Checking a patient in restraint:

(a) A patient in restraint must be checked at least every 15 minutes;

(b) Attention shall be paid to the patient’s basic personal needs (such as regular meals, personal hygiene, and sleep) as well as the patient’s need for good body alignment and circulation;

(c) Staff shall document that the patient was checked and appropriate attention paid to the person’s needs.

(8) During waking hours the patient must be exercised for a period not less than 10 minutes during each two hours of physical restraint. Partial release of physical restraint shall be employed as necessary to permit motion and exercise without endangering other staff and patients.

(9) Unless the order authorizing use of restraint specifically provides otherwise, the patient shall be released as soon as it is reasonable to assume that the behavior causing use of restraint will not immediately resume if the patient is released.

(10) OAR 309-112-0015 and 309-112-0017 require staff of state institutions to apply the most appropriate form of restraint consistent with the patient’s behavior requiring intervention, the need to protect the staff and other patients, the patient’s treatment or training needs and preservation of the patient’s sense of personal dignity and self-esteem. The determination of the most appropriate intervention requires consideration of the following factors:

(a) The individual patient involved; e.g., the present physical ability to engage in violent or destructive behavior, any preference the individual patient has for one method of behavior management versus another, and the patient’s reaction to various methods of intervention;

(b) The risk or degree of physical or psychological harm and discomfort that accompany the various methods of intervention;

(c) The risk or degree of interference with the individual’s ongoing treatment or training and other activities.

(11) A summary of all uses of restraint, other than personal restraint for 15 minutes or less, shall be sent to the chief medical officer at least monthly.

(12) The following types of procedures are part of ordinary and customary medical care for physical illnesses or conditions and are not subject to the provisions of these rules:

(a) Holding or restraining a patient during an examination, blood drawing, performance of a diagnostic test or during treatment for an acute medical condition;

(b) Restricting movement with orthopedic devices such as casts, wheel chairs, braces, and positioning devices;

(c) Isolating a patient with a known or suspected infectious disease;

(d) Protecting seizure-prone and self-abusive patients by the use of protective gear.

(13) A patient, guardian, or a duly authorized representative of the patient, or guardian has the right to contest any application of these rules as provided in OAR 309-118-0000 through 309-118-0050 (Grievance Procedures for Use in State Institutions).

(14) Violation of the rights, policies, and procedures set forth in these rules by an employee of the Division constitutes cause for disciplinary action.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 11-1982(Temp), f. & ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHD 16-1985(Temp), f. & ef. 10-9-85; MHD 2-1986, f. & ef. 3-31-86; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0015

Use of Restraint in Emergencies

(1) Subject to the provisions of these rules, restraint may be used to manage the behavior of a patient in emergencies. An emergency exists, as determined by the chief medical officer or designee if, because of the behavior of a patient:

(a) There is a substantial likelihood of immediate physical harm to the patient or others in the institution; and

(b) There is a substantial likelihood of significant property damage; or

(c) The patient’s behavior seriously disrupts the activities of other patients on the unit or cottage; and

(d) Measures other than the use of restraint are deemed ineffective to manage the behavior.

(2)(a) When an emergency exists, the staff of a state institution shall select the most appropriate intervention consistent with OAR 309-112-0010(9);

(b) Whenever the interdisciplinary team (IDT) has reason to believe that in the course of a patient’s care, custody, or treatment at a state institution it may become necessary to use restraint in an emergency, a member of the IDT shall, if practicable, ask the patient for an expression of preference or aversion to the various forms of intervention. A member of the IDT shall also ask the parent or guardian for an expression of preference regarding forms of intervention. The patient’s expression, if any, as well as that of the parent or guardian shall be relayed to the other IDT members and recorded in the patient’s chart;

(c) The patient’s wishes for or against particular forms of intervention shall be respected by the person authorizing the use of restraint, provided that primary consideration shall be given to the need to protect the patient and others in the institution.

(3) Authorization:

(a) Except as provided in subsections (3)(d) and (e) of this rule, restraint shall be administered only pursuant to the order of the chief medical officer or the chief medical officer’s designee;

(b) For the purposes of this section, the chief medical officer may designate one or more of the following persons: A physician licensed to practice medicine in the State of Oregon, a psychologist, or a psychiatric/mental health nurse practitioner;

(c) The chief medical officer or designee shall order the use of restraint only after adequately assessing the patient’s condition and the environmental situation;

(d) If the chief medical officer or designee is not available immediately to assess the need for intervention, and an emergency exists as defined in section (1) of this rule:

(A) The person in charge of the unit or cottage at the time:

(i) May authorize temporary use of restraint for a period of time not to exceed 30 minutes; and

(ii) Shall immediately contact the chief medical officer or his or her designee.

(B) The chief medical officer or designee shall personally observe the patient as soon as practicable to assess the patient and assess the appropriateness of the temporary use of restraint. The observation shall be documented in the person’s chart.

(e) Every incident of personal restraint must be ordered by the chief medical officer or his or her designee, or as provided in subsection (3)(d) of this rule. The order may be oral or written but shall be documented as provided in section (4) of this rule.

(4) Documentation:

(a) No later than the end of their work shifts, the persons who authorized and carried out the use of restraint shall document in the patient’s chart including but not necessarily limited to:

(A) The specific behavior which required intervention;

(B) The method of intervention used and the patient’s response to the intervention; and

(C) The reason this specific intervention was used.

(b) Within 24 hours after the incident resulting in the use of restraint, the chief medical officer or designee who ordered the intervention shall review and sign the documentation. In the case of patients detained in a psychiatric hospital pursuant to an emergency hold under ORS 426.180 through 426.225, the treating physician shall sign the documentation, if the treating physician is not the chief medical officer or designee who ordered the intervention.

(5) Time Limits: All orders authorizing use of restraint shall contain an expiration time, not to exceed 12 hours and consistent with OAR 309-112-0010(8). Upon personal re-examination of the patient, the chief medical officer or designee may extend the order for up to 12 hours at each review, provided that the behavior of the patient justifies extended intervention. After each 24 hours of continuous restraint, a second opinion from another designee of the chief medical officer shall be required for further extension of the restraint.

(6) Reporting: Under this rule all emergency uses of restraint in excess of 15 minutes shall be reported daily to the chief medical officer or designee.

(7) After the second use of emergency restraint on a particular patient during a one-month period, a treatment program designed to reduce the need for restraint must be developed.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHD 2-1986, f. & ef. 3-31-86; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0017

Use of Restraint as Part of Planned Treatment or Training Programs

Subject to the provisions of these rules, restraint may be used as part of planned treatment program provided the informed consent of the patient is obtained or, if informed consent cannot be obtained, authorization to proceed with necessary treatment is obtained as provided in OAR 309-114-0000 through 309-114-0025.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 11-1982(Temp), f. & ef. 6-10-82; MHD 21-1982, f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0020

Use of Security Transportation

The chief medical officer or designee may authorize the use of secure transportation for patients of a secure program when outside the security area.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 22-1982(Temp), f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0025

Use of Restraint for Acute Medical Conditions

(1) During medical treatment for acute physical conditions, personal and physical restraint may be used to prevent a patient from injuring himself or herself.

(2) Use of a restraint in the presence of a physician may be authorized verbally; ongoing or continuing use of personal or physical restraint must be ordered in writing by a physician.

(3) Treatment staff shall:

(a) Attend to the patient’s basic personal needs and exercise needs in accordance with general medical practice; and

(b) To the extent practicable, accommodate the patient’s mental disabilities treatment and training regimen.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0030

Restraint Review Committee

(1) Each state institution shall have a Restraint Review Committee. The members of the committee shall be appointed by the superintendent of each institution and shall consist of five members; two from institution staff and three community persons who are knowledgeable in the field of mental health. A quorum shall consist of three members. The committee may be one formed specifically for the purposes set forth in this rule, or the duties prescribed in this rule may be assigned to an existing committee.

(2) The purpose and duty of the Restraint Review Committee is to review and evaluate at least quarterly the appropriateness of all such interventions and report its findings to the superintendent.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 12-1982, f. & ef. 6-10-82; MHD 22-1982(Temp), f. & ef. 9-24-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

309-112-0035

Notice to Patients and Employees

(1) Upon admission, state institutions shall inform patients orally and in writing, of the rights, policies, and procedures set forth in these rules. In addition, a clear and simple statement of the title and number of these rules, their general purpose, and instructions on how to obtain a copy of the rules and how to seek advice about their content shall be prominently displayed in areas frequented by patients in all state institutions.

(2) All employees of state institutions shall be notified in writing at the commencement of their employment, or, for present employees, within a reasonable time of the effective date of these rules, of the rights, policies, and procedures set forth in these rules.

Stat. Auth.: ORS 179.040 & 413.042
Stats. Implemented: ORS 426.385
Hist.: MHD 1-1982(Temp), f. & ef. 1-14-82; MHD 7-1982, f. & ef. 3-29-82; MHD 1-1984, f. 1-20-84, ef. 2-1-84; MHS 2-2013(Temp), f. & cert. ef. 1-23-13 thru 7-19-13; Administrative correction, 8-21-13; MHS 6-2015(Temp), f. 10-20-15, cert. ef. 10-21-15 thru 4-15-16; MHS 2-2016, f. & cert. ef. 4-21-16

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