Inspection

General Information

Is the patient in Restraint?

Is the patient in Seclusion?

The name of the personnel applying the restraint or seclusion is documented

The staff applying the restraint or seclusion has competencies for restraint and seclusion

Type of Restraint (nonviolent or violent/DTS or DTO)?

There is clinical justification documented in the record for the type of restraint or seclusion applied

Hospital policy addresses who can initiate the emergency application of restraint prior to obtaining and order from a qualified LP

Non-Violent Non-Self-Destructive Restraint

There is a licensed practitioner order for the restraint or seclusion

The order is time limited according to policy and the type of restraint or seclusion

The restraint order is renewed in the timeframe required by policy (AHS = Daily)

Less restrictive measures have been tried

The use of alternatives and less restrictive methods is documented

The least restrictive type or techniques of restraint or seclusion has been implemented

The restraint has been applied safely

The attending was notifies as soon as possible after the patient was placed in restraint or seclusion

The order for nonviolent or nonselfdestructive reasons has been renewed within the timeframe required by hospital policy (daily)

Restraint or seclusion orders are not written as PRN orders

The restraint/seclusion has been discontinued at the earliest possible time

Patients are assessed immediately after application of restraint to assess for injury, physical and psychological status and other needs

The patient's Interdisciplinary Care Plan is updated to include the use of restraint or seclusion

The patient/family is provided restraint education/information and explain reason for restraint/seclusion

The education is documented

The patient in nonviolent/nonselfdestructive restraint is monitored at least every two hours for release of restraints

The patient in nonviolent/nonselfdestructive restraint is monitored at least every two hours for circulation and skin condition

The patient in nonviolent/nonselfdestructive restraint is monitored at least every two hours for provision of exercise or range of motion and allow for position change

The patient in nonviolent/nonselfdestructive restraint is monitored at least every two hours for nutrition, hydration, hygiene and elimination needs

Reassessment and restraint release during care measures is documented.\

The monitoring is documented in the medical record

The restraint log or "denial of rights" log reflects the restraint or seclusion

Violent or Danger to Self/Others

There is a licensed practitioner order for the restraint and/or seclusion

The order is time limited according to policy and the type of restraint or seclusion

The restraint order is renewed in the timeframe required by policy

Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:

4 hours for adults 18 years of age or older;
2 hours for children and adolescents 9 to 17 years of age; or
1 hour for children under 9 years of age

After 24 hours, a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law must see and assess the patient.

Less restrictive measures have been tried

The use of alternatives and less restrictive methods is documented

The least restrictive type or techniques of restraint or seclusion has been implemented

The restraint/seclusion has been applied safely

If applied emergently, the order was obtained during the emergency or immediately (a few minutes) after the restraint or seclusion

The attending was notifies as soon as possible after the patient was placed in restraint or seclusion

When restraint or seclusion is used for management of violent or self-destructive behavior the patient is seen face-to-face within one hour after initiation of the intervention by either a physician/other LP, or RN who has been trained to do so

The face-to-face is not conducted telephonically or by telemedicine

The face-to-face documents the patient's immediate situation

The face-to-face documents the patient's reaction to the intervention

The face-to-face documents the need to continue or discontinue the restraint or seclusion

If the face-to-face is done by the RN, the RN has consulted the attending physician or other LP responsible for the patient's care after completion of the evaluation

Restraint or seclusion orders are not written as PRN orders

The restraint/seclusion has been discontinued at the earliest possible time

Patients in restraint AND seclusion are continuously monitored

Patients in restraint or seclusion for violent or self-destructive behavior are monitored every 15 minutes for signs of injury associated with the application of restraint or seclusion

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for nutrition/hydration

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for circulation, range of motion in the extremities and position change

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for vital signs

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for hygiene and elimination

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for physical and psychological status and comfort

Patients in restraint for violent or self-destructive behavior are monitored every 15 minutes for readiness for discontinuation of restraint

Patients are assessed immediately after application of restraint to assess for injury, physical and psychological status and other needs

The patient's Interdisciplinary Care/Treatment Plan is updated to include the use of restraint or seclusion

The patient/family is provided restraint education/information and explain reason for restraint/seclusion

The education is documented

The monitoring is documented in the medical record

The restraint log or "denial of rights" log reflects the restraint or seclusion

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.