Schoolcraft v. The City Of New York et al

Filing 326

DECLARATION of Gregory J. Radomisli in Support re: 325 MOTION for Summary Judgment .. Document filed by Jamaica Hospital Medical Center. (Attachments: # 1 Exhibit Exhibit A, # 2 Exhibit Exhibit B, # 3 Exhibit Exhibit C part 1, # 4 Exhibit Exhibit C part 2, # 5 Exhibit Exhibit D, # 6 Exhibit Exhibit E part 1, # 7 Exhibit Exhibit E part 2, # 8 Exhibit Exhibit E part 3, # 9 Exhibit Exhibit F, # 10 Exhibit Exhibit G, # 11 Exhibit Exhibit H, # 12 Exhibit Exhibit I, # 13 Exhibit Exhibit J, # 14 Exhibit Exhibit EE, # 15 Exhibit Exhibit FF, # 16 Exhibit Exhibit HH)(Osterman, Brian)

THE JAMAICA HOSPITAL MEDICAL CENTER
DEPARTMENT OF PSYCHIATRY MANUAL

SUBJECT:

USE OF RESTRAINTS FOR PRIMARY BEHAVIORAL HEALTH NEEDS

ISSUED:

4/95

REVISED:

11/95,
04/05,

6/96, 10/99, 4/00, 4/01, 6/02, 4/03,
04/06, 04/07, 04/08, 04/09, 4/10

04/04,

I.

PHILOSOPHY
Restraint can be defined as any physical method of
restricting a person's freedom of movement, physical activity,
or normal access to his or her body. Jamaica Hospital Medical
Center recognizes that all patients have the right to
considerate, respectful care at all times and under all
circumstances, with recognition of their personal dignity,
privacy and safety, in the least restrictive environment.
Restraints will only be used for the safety of patients or
others when all other interventions have been exhausted.
Patient's safety needs will be individually evaluated and the
least restrictive, effective type of intervention/restraint
utilized.
II.

POLICY
There are times in which a patient's behavior may
necessitate the use of restraints.
Physical restraints shall be
used to prevent a patient from injuring self or others, and only
as a last resort when all other available psychological or
physical modalities are ineffective. Restraints may not be
employed as punishment, for the convenience of staff, or as a
substitute for treatment programs.
When a patient requests
restraints that are considered therapeutic, the restraints
procedures shall be implemented according to the guidelines
outlined in this policy.A risk assessment must be made in regard
to a patient's medical condition(e.g. cardiac, respiratory) and
abuse issues prior to placement in restraints. All patients
requiring restraints must be restrained in the least restrictive
fashion and for the least amount of time appropriate to their
medical condition and their mental status. The restraint must be
ordered in writing by a physician after a face to face
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evaluation or in an emergency initiated by a registered nurse
If initiated by a registered nurse the physician must be
consulted as soon as possible and the restraint order must be
written by a physician within 30 minutes after a face to face
evaluation of the patient.

EXCEPTIONS:
A.
These guidelines do not cover those devices
customarily used in conjunction with medical, diagnostic,
surgical procedures/treatments or movement/transfer of patients
when such cases are considered a regular or usual part of
treatment, e.g., body restraint (during surgery). Nor do
they include safety restraints for children in cribs, high
chairs or strollers or the use of medically indicated devices
that are intended to stabilize a body part, e.g., back brace or
splint.
They do not include commonly used devices which allow
all extremities uninhibited movement, such as bed rails,
tabletop chairs, wheelchair trays or gerichairs.
B. This policy does not apply to forensic and correction
restrictions used for security purposes.
IV.

PURPOSE
To establish guidelines for the safe, effective use of
restraints in accordance with state and federal regulations.
This policy is applicable to all patients presenting in the
outpatient/inpatient programs and applies to these interventions
that are used involuntarily as indicated by individual orders.
Specifically, it is to maintain patient's safety and protect
from injury to self and others.
V.

RESPONSIBILITY
1) It is the responsibility of the physician/psychiatrist
to assess and determine the clinical situation for the use of
restraints.

2) Using the preprinted physician/psychiatrist order form
for "PRIMARY BEHAVIORAL HEALTH NEEDS " the physician orders the
type of restraints to be used, specifies the length of time the
order is effective and checks off the reason for the restraints
(see attached form).
'
3) The physician must review the patient's chart paying
special attention to the plan of care and medication.
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4)
The registered nurse can place a patient in restraints
in an emergency situation if the activity the patient is
engaging in presents an immediate danger to self and others. The
physician must be summoned immediately and the supervising nurse
notified. It is the responsibility of the notified physician to
document in the clinical record, the reason/s for not responding
within the thirty minutes time period.
5)
Under the direction of the registered nurse, nursing
staff apply and remove restraints, provide constant observation,
assessments and nursing care.
VI.

PROCEDURE
1) A patient should only be placed in restraints if their
behavior presents a danger to self or others. Use of restraints
is based on the patient's needs in the immediate care
environment and the interaction of the patient and the staff
with other patients in that environment and not solely on prior
history of use or history of dangerous behavior. Less
restrictive interventions must be considered before the ordering
of restraints. Less restrictive interventions includes but are
not limited to physiologic assessment, verbal intervention,
quiet room, companionship, constant observation, medication
offered, environmental change etc.
2) All contrabands must be removed from patients before
placing them in restraints.
3) Written orders for restraint of patients with primary
behavioral health needs are time limited to:
□
4 hours for adults
□
2 hours for children and adolescents ages 9-17
□
1 hour for patients under age 9
4) If the patient still need restraints after the initial
episode then the patient must be re-evaluated by a physician and
a new order written and restraint policy and procedure followed.
5) If an emergency situation exists in which the patient is
engaging in an activity that presents an immediate danger to
self or others and a physician is not immediately
available, restraints may be initiated under the direct
supervision of a registered nurse. The physician must respond
within thirty minutes to assess the patient and write
the
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order for restraints. In no event shall restraint be applied for
longer than one hour without the written order of a physician.
6) A patient may only be placed in restraint under the
supervision of a registered nurse.
7) Nursing staff are authorized to apply and remove
restraints.

,
•

8) Security officers may be called to assist in holding an •'
agitated/combative dangerous patient while nursing staff apply
restraints.
.
9) The: following assessments must be made and documented on
the Restraint/Seclusion Progress Record every 15 minutes by
Nursing Staff.
□

♦

♦

Circulation check/skin condition of the restrained
limbs taking note of color, sensation, temperature
changes and tightness.
Changes in mental status, level of anxiety and
agitation., psychomotor activities, verbal, and
nonverbal behavior.
Patient awake or asleep.
J

10)
The following physical care must be provided as needed
or at least every hour by the Nursing Staff in addition to the
above.
j
♦
♦

♦
♦
♦
♦

Adjust restraint application;
Allow patient to feed self; if appropriate. Raise
head part of the bed and feed patient in an upright
position only.
Additional fluids between meals;
Offer snacks;
Mouth care;
Toileting

11) Complete vital signs including BP must be taken and
assessed at the initiation
of restraints if possible, every hour afterwards, and the end of
the restraint period
or as indicated by the patient's condition and/or physician's
order.
Pulse and respiration must be taken every 15 minutes.
If unable to take vital signs it must be so documented.
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12)
Restraints must be released, a limb at a time, every
hour for 5-15 minutes except when the patient is asleep or still
combative. When restraints are released, the
areas restrained should be inspected, massaged (unless
contraindicated) and skin lotion applied. Range of motion
exercises should be provided and the patient is to be
repositioned when possible. Toileting and nourishment should be
offered at this time .
13)
A patient in restraint shall be released from
restraint every two hours, except if still agitated or when
asleep.
14)
All patients placed on restraints must be placed on
CONSTANT OBSERVATION for the duration of restraints.
15) There must be a staff and patient debriefing after each
application of restraints.
VII.

DISCONTINUATION OF RESTRAINTS
•1)
A physician may order the discontinuation of
restraints.

2)
A registered nurse may release a patient from
restraints prior to the order's
expiration time if the patient's condition improves eg less
agitated, able to contract for safety and control behavior. The
physician must be contacted immediately.
3)
If a patient is released from restraints prior to the
expiration of an order and the patient threatens to hurt self or
others, the patient may be re-restrained pursuant to a new
physician's order.

VIII, DOCUMENTATION
1) The physician must order the restraint in writing on the
preprinted order form for "Primary Behavioral Health Needs".
2) On the Restraint/Seclusion Progress Record, the
registered nurse enters the date, starting and ending times, the
unit's name, the type of restraint ordered, and the
interventions attempted prior to implementing restraints. The
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DEPARTMENT OF PSYCHIATRY MANUAL

physician and registered nurse dates and times their brief
evaluation notes.
3)
The initial physician and nurse progress note must be
dated, timed and the reason/indication for the application of
restraints and the type of restraints used must be documented.
The progress notes must also indicate that the procedure was
explained to the patient/family when possible or that an attempt
was made.
4) Nursing staff assessments/notes must be done every
fifteen (15) minutes when the patient is placed in restraint.
These must be recorded on the Restraints/Seclusion Progress
Record.
5) Prior to each subsequent period of restraints, a
progress note must be written to include a description of the
patient's physical activity, verbal content, notation of
nourishment and elimination needs, and provision for personal
hygiene.
6) When restraints are discontinued, a progress note must
indicate the date, time and description of the behavior and if
any injuries were suffered by the patient.
IX.

FAMILY AND PATIENT EDUCATION
Episodes of restraints must be considered in the treatment
planning process and addressed by appropriate goals, objectives
and actions as indicated.
Families must be informed of episodes
of restraint if patient consents and be so documented.
Families
and patients must be educated and involved in the treatment
process when appropriate.
X.

LOCATION OF RESTRAINED PATIENTS
Patients are to be restrained in an area where they can be
observed by staff with respect for their dignity.
Restrained
patients must be kept in a safe environment where they are
protected from other potentially violent or provocative patients
or visitors.
XI. TYPES OF RESTRAINTS
1) Restraints must be approved commercial restraints or
non-commercial
„

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restraints made of unbleached muslin with quilted center
portions or nylon with Velcro straps. Permitted forms of
restraints are:
□
Camisoles
□
Wrist and ankle restraints ( 4 point) and 5
point- added soft restraint across the chest.
Mittens
□
The above restraints are located in the nurses' station of each
unit.
Plain bed sheets and locked restraints must never be used to
restrain a patient.
2) It is never appropriate for clinical personnel to write
an order for restraint by handcuffs. Handcuffed patients brought
to the hospital by law enforcement officers must be quickly
assessed to determine if the handcuffs can be safely and
immediately removed.
XII.

PERFORMANCE IMPROVEMENT
The use of restraints is part of the Performance
Improvement process of the hospital. Concurrent reviews of
patients placed in restraints and medical records of patients
placed in restraints will be reviewed for the appropriateness of
restraints, the adequacy of patient monitoring, and the
completion of documentation. A log book of all episodes of
restraints is maintained on each unit which includes the date,
time, patients' name, reasons for restraints, type of restraint
and the person who made the decision to place the patient in
restraint. All data is analyzed/used to identify opportunities
for improvement. Particular attention is paid to instances of
multiple episodes of use for individual patients and the
frequency of restraints used by each staff member. The clinical
leadership of the department is notified of any instance in
which a patient remains in restraint for more then 12 hours, or
experiences two or more separate episodes of restraint of any
duration within 12 hours.
XIII. EDUCATION AND COMPETENCY
Competent staff are essential to using restraints safely
and to protect the patient during use. Appropriate ongoing
training for staff will be provided. Only those staff members
trained in the specific use of restraints may apply them. Staff
will apply restraints according to the manufacturer's
directions. Competency in the application of restraints will be
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DEPARTMENT OF PSYCHIATRY MANUAL
assessed after the appropriate training. The patient, their
family and significant others will be educated on the reason for
restraints, the treatment plan and all efforts to use less
restrictive means. They will be encouraged to participate in the
treatment planning.