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7.3.1
Introduction
The use of seclusion and restraint can be a high-risk intervention
that must be used only when less restrictive and less intrusive
approaches have failed. Because of the high potential for injury,
guidelines have been established to closely monitor the use of seclusion
and restraint in Level I inpatient facilities licensed by the Office
of Behavioral Health Licensure (OBHL).
This section
is intended to describe seclusion and restraint reporting requirements
for licensed Level I facilities authorized to use seclusion and
restraint as a behavioral health intervention.
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7.3.2
References
The following citations can serve as additional resources for this
content area:
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7.3.3
Scope
To whom does this apply?
To all T/RBHA
contracted OBHL licensed Level I behavioral health facilities authorized
to use seclusion and restraint.
7.3.4
Objectives
To establish reporting requirements regarding the use of
seclusion and restraint.
7.3.5
Did you know…?
- Each State
has a designated protection and advocacy system. In Arizona, the
Arizona Center for Disability Law serves as the designated protection
and advocacy agency.
- Each
T/RBHA is also required to collect certain aggregate data that
compiles total seclusion and restraints for the reporting period,
and forward that data to ADHS/DBHS.
- The
Harvard University Center for Risks Analysis estimates that between
50 and 150 deaths occur as a result of restraint or seclusion
every year across the country.
- Trauma associated
with seclusion and restraint can trigger Post Traumatic Stress
Disorder
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7.3.6
Definitions
Drug
used as a Restraint
Mechanical
Restraint
Personal
Restraint
Restraint
Seclusion
7.3.7
Procedures
7.3.7-A.
Reporting to the T/RBHA
Licensed Level I facilities authorized to use seclusion
and restraint must report each occurrence of seclusion and restraint
to the T/RBHA within five days of the end of the occurrence. The
report must be submitted on PM Form 7.3.1, Seclusion and Restraint
Reporting-Level I Facilities.
Licensed Level
I facilities must submit a report of the total number of occurrences
of the use of seclusion and restraint that occurred in the prior
month by the 5th calendar day of each month to the T/RBHA. If there
were no occurrences of seclusion and/or restraint during the reporting
period, the report should so indicate. Monthly summary data is to
be submitted to the Gila River RBHA Manager of Quality Management/Utilization
Management utilizing PM Form 7.3-GR.
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7.3.7-B. Reporting to the Office of Human
Rights
Licensed Level I facilities authorized to use seclusion and restraint
must report any occurrence of the use of seclusion and restraint
with persons determined to have a serious mental illness or children
to the Office of Human Rights by the 10th day of every month.
The report must
also be filed with the human rights committee for the T/RBHA associated
with the facility.
7.3.7-C.
Reporting to the Office of Behavioral Health Licensure
An OBHL licensed agency must notify OBHL within one working day
of discovering a death or physical injury that requires medical
services, including injuries or deaths of persons that occur as
a result of a seclusion and/or restraint. This notification must
be followed up by a written incident report within five days of
initial notification. For more information regarding this subject,
follow the guidelines in Section 7.4, Reporting of Incidents, Accidents
and Deaths.
7.3.7-D. Other reporting requirements
Because of the high-risk nature of seclusion and restraint interventions,
it is possible that a person may be injured or that a “serious
occurrence” may occur during a seclusion and restraint event.
A serious occurrence includes a person’s death, a serious
injury to a person and/or a suicide attempt by a person. OBHL licensed
Level I behavioral health facilities are required to report any
serious occurrences, including those that occur as a result of a
seclusion and restraint event, to AHCCCS and The Arizona Center
for Disability Law (see contact information below) no later than
the close of business the next business day following the serious
occurrence. In addition, in the case of a person’s death,
the information must also be reported to the Center for Medicare
and Medicaid Services (CMS) Regional Office. For more information
regarding this subject, follow the guidelines in Section 7.4, Reporting
of Incidents, Accidents and Deaths.
Documentation
that the reports of serious occurrences were made to AHCCCS, the
Arizona Center for Disability Law and CMS (if applicable) and the
names of the individuals who received the report at each entity
must be included in the person’s comprehensive clinical record
and in the incident/accident report log of the facility.
For reporting
of serious occurrences:
AHCCCS
FAX Number (602) 417-4855-Attention DHCM Senior Clinical and Quality
Consultant for Behavioral Health
The Arizona
Center for Disability Law
FAX Number (602) 274-6779-Attention Ann Rider
CMS Regional
Office (to report a death only)
FAX Number (415) 744-2692-Attention Mary Frances Colvin
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7.3
Seclusion and Restraint Reporting
Last Revised: 07/02/2004
Effective Date: 08/01/2004 |
