AHS - Restraint & Seclusion Checklist 2020

• Conducted on

  Date

• Prepared by

• Campus

  Select

• Clinical Unit

• Patient Identifier (MRN #)

General Information

• Is the patient in Restraint?

  Yes

  No

  N/A

• Is the patient in Seclusion?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Select

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Non-Violent Non-Self-Destructive Restraint

• There is a licensed practitioner order for the restraint or seclusion

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Less restrictive measures have been tried

  Yes

  No

  N/A

• The use of alternatives and less restrictive methods is documented

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The restraint has been applied safely

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Restraint or seclusion orders are not written as PRN orders

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The education is documented

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Reassessment and restraint release during care measures is documented.\

  Yes

  No

  N/A

• The monitoring is documented in the medical record

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Violent or Danger to Self/Others

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The restraint order is renewed in the timeframe required by policy

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• The use of alternatives and less restrictive methods is documented

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The restraint/seclusion has been applied safely

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• Restraint or seclusion orders are not written as PRN orders

  Yes

  No

  N/A

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

  Date

• Patients in restraint AND seclusion are continuously monitored

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The education is documented

  Yes

  No

  N/A

• The monitoring is documented in the medical record

  Yes

  No

  N/A

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

  Yes

  No

  N/A