Restraints and Seclusion

Restraint and seclusion can only be used in emergencies!

State and federal laws prohibit the use of restraint and seclusion except when it is to prevent imminent physical injury to the patient or others and other measures have failed.  Staff must use the least amount of restraint and seclusion necessary to stop the emergency.  The law requires that restraints and seclusion be used in the least restrictive manner possible; and ended at the earliest possible time.

• Patients in restraint or  seclusion must receive active treatment;
• Staff must explain to the patient behavioral criteria for the discontinuation of restraint or seclusion;
• Patients and staff must be debriefed after each episode of restraint and seclusion;
• Patients may have family members and/or advocates notified each time restraint and seclusion are initiated.

Staff must try to de-escalate the situation before using restraint or seclusion.

Successful de-escalation requires the staff get to know the patients.  The DMHAS Clinical Assessment process mandates an assessment of every patient to determine their potential for behavioral dyscontrol.  For people with no history or potential for behavioral dyscontrol, the Assessment identifies adaptive coping skills.  For people with a history or potential for behavioral dyscontrol, the Assessment identifies the specific factors that are known to increase the potential for behavioral dyscontrol.  People should also be assessed to determine what measures are known to be clinically safe and effective to prevent and manage dangerous behavioral control (Personal Safety Preferences).  The Assessment should be a part of every patient’s Individual Treatment Plan.

Restraint and seclusion cannot be ordered on an “as needed” or “PRN” basis.

Federal regulations and DMHAS policy forbid the use of "standing orders" (often called “PRN”) for the use of restraint and seclusion.  Each use of restraint and seclusion must be separately and specifically authorized on each occasion, and only after attempts at de-escalation and less restrictive measures have failed.

A doctor must conduct a face-to-face assessment within 1 hour of the application of restraints or use of seclusion.  Restraint orders can be written for a maximum of 3 hours.  However, a patient must be removed from restraints at the earliest possible time, which may be less than the 3 hour limit. 

Restraint orders can be renewed only if the danger continues.

A physician (nurse between the hours of 11 pm and 8 am) conducts a face to face assessment of the patient.  If the patient remains an immediate danger to self or others, a restraint order may be renewed for an additional 3 hours.

The use of restraint and seclusion is documented and monitored.

 The condition of a patient who is restrained or secluded must be monitored through continuous observation and regular reassessment and evaluation.  The assessment includes:  signs of injury associated with the application of restraint or seclusion; nutrition/hydration; circulation and range of motion in the extremities; vital signs; physical status and comfort; mental status and patients preferences for conversation, silent companionship, distraction; and readiness for discontinuation of restraint or seclusion. All of the activities related to the use of restraints must be specifically documented in the patient’s record, including the efforts made to de-escalate and use less restrictive alternatives. 

The use of restraint or seclusion must be reported to both the facility Medical Director and the Director of Nursing for review the next business day.  The review must include investigation of patterns, and the use of data to reduce the use of restraint and seclusion.  In addition, monthly reports on the use of restraint and seclusion must be submitted to the Commissioner’s office, and any serious injuries or deaths related to the use of restraints must be reported to the Office of Protection and Advocacy for Persons with Disabilities.

Staff training is required.

Federal regulations and DMHAS policies require staff training on restraint and seclusion, including the use of de-escalation techniques, less restrictive alternatives, the safe application of restraints, and monitoring practices.

Policies regarding the use of restraint and seclusion and reporting misuse.

The use of restraint and seclusion to restrict the movement of persons with psychiatric disabilities has been the focus of considerable attention in the past few years.  “Deadly Restraint,” an award-winning series of articles in the Hartford Courant in late 1998, highlighted the large number of tragic deaths associated with the use of restraint.  The articles spawned federal and state laws aimed at reducing, if not eliminating, the use of restraints.

The federal Center for Medicaid and Medicare Services (CMS, formerly known as “HCFA”) oversees both the Medicaid and Medicare programs, and monitors hospital compliance with its new regulations.  To date, CMS has found at least one Department of Mental Health and Addiction Services (DMHAS) facility out of compliance with restraint and seclusion regulations.  As a result of this finding, DMHAS adopted and is implementing a new set of restraint and seclusion policies.

The policies are comprehensive and they must be followed on all units, across shifts, throughout the system.  You can request a copy of the DMHAS policy at any DMHAS facility.  If you, or someone you know, has been subjected to restraints or seclusion, make sure all of the rules were followed.

If the policy wasn’t followed, report violations using:

• DMHAS grievance process, for state funded facilities;
• Protection and Advocacy, for privately funded facilities;
• Department of Public Health complaint; and/or CMS.

You may decide to make a complaint regarding the use of restraint or seclusion.  CT Legal Rights Project has legal advocates available to assist you with the process at all DMHAS facilities.

Patients in restraint or seclusion have the right to advocacy services!

Every individual in the DMHAS system has the right to advocacy services, and this is particularly important for persons whose freedom is being restricted through the use of physical restraint or seclusion.  Hospital personnel should inform patients about their right to advocacy services, and contact an advocate on behalf of a patient in restraint or seclusion, if requested to do so.

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