This chapter establishes standards for the use of isolation and restraint in Tennessee hospitals providing inpatient mental health services. Operators must develop policies and procedures governing authorization, time limits, monitoring, assessment, staff training, internal review, and reporting requirements for all forms of isolation and restraint (isolation/seclusion, mechanical restraint, physical holding, and chemical restraint). Hospitals must conduct risk assessments, follow strict monitoring intervals, notify legal surrogates within 12 hours of any episode, and report aggregate data and deaths to TDMHSAS annually or by the next business day, respectively.
View official sourceDecember, 2022 (Revised) 1 RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES DIVISION OF MENTAL HEALTH SERVICES CHAPTER 0940-03-06 HOSPITAL ISOLATION AND RESTRAINT TABLE OF CONTENTS 0940-03-06-.01 Scope 0940-03-06-.11 Behavioral Criteria for Release 0940-03-06-.02 Definitions 0940-03-06-.12 Monitoring and Assessment of Continued 0940-03-06-.03 Purpose of Isolation or Restraint Need 0940-03-06-.04 Application of This Chapter 0940-03-06-.13 Location of Use 0940-03-06-.05 Policies and Procedures 0940-03-06-.14 Termination 0940-03-06-.06 Initiation of Isolation or Physical Restraint in 0940-03-06-.15 Notification of Legal Surrogates the Absence of a Licensed Independent 0940-03-06-.16 Notification of Family/Significant Other Practitioner 0940-03-06-.17 Internal Reviews 0940-03-06-.07 Authorization 0940-03-06-.18 Performance Improvement Activities 0940-03-06-.08 Length of Authorization 0940-03-06-.19 Training 0940-03-06-.09 Renewal 0940-03-06-.20 Reporting 0940-03-06-.10 Assessments 0940-03-06-.01 SCOPE. (1) This chapter applies to all facilities providing inpatient mental health services in a hospital without regard to source of licensure, certification or accreditation. Isolation and restraint may be used in such settings only in compliance with this chapter. (2) Isolation or restraint in mental health treatment settings other than hospitals is governed by chapters applicable to those settings. Chemical restraint is permissible only in a hospital and in compliance with this chapter. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.02 DEFINITIONS. (1) Chemical Restraint: A medication that is prescribed to restrict the serv ice recipient’s freedom of movement for the control of extr eme violent physical behavior. Chemical restraints are medications used in addition to, or in replacement of, the service recipient’s regular drug regimen to control extreme violent physical behavior. The medications that comprise the service recipient’s regular medical regimen (including PRN medications) are not considered chemical restraints, even if their purpose is to treat ongoing behavioral symptoms. (2) Conservator: A court appointed conservator or a Veterans Administration guardian. (3) Hospital: A licensed public or private inpatient treatment resource or hospital or a part of a hospital that provides inpatient care and treatment for persons with ment al illness or serious emotional disturbance. (4) Isolation: The confinement of a service recipient alone in a room or an area where the service recipient is physically prevented from leaving. This defin ition is not limited to instances in which a service recipient is confined by a locked or closed door. This definition explicitly excludes the segregation of a service recipient for the purpose of managing biological contagion consistent with the Centers for Disease Control Guidelines. HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.02, continued) December, 2022 (Revised) 2 Isolation does not include confinement to a locked unit or ward where other individuals are present. Isolation is not solely confinement of a service recipient to an area, but separation of the service recipient from other persons. Isolation does not include time- out, which i s a behavior management procedure in which, contingent upon the demonstration of undesired behavior, the opportunity for positive reinforcement is withheld, which may involve the voluntary separation of the individual service recipient from others. (5) Licensed Independent Practitioner: An individual licensed by the Tennessee Health Related Boards as a: (a) Medical doctor; (b) Doctor of osteopathy; (c) Physician assistant; (d) Certified nurse practitioner; (e) Nurse with a masters degree in nursing who functions as a psychiatric nurse; (f) Psychologist with health service provider designation; (g) Licensed clinical social worker; (h) Licensed professional counselor; (i) Senior psychological examiner; (j) Psychological examiner (k) Marriage and family therapist; or (l) Other licensed mental health professional who is permitted by law to practice independently. In addition, to be considered a licensed independent practitioner for purposes of t his chapter, the individual must be privileged by the hospital medical staff and governing body to authorize the use of isolation and restraint. (6) Licensed Mental Health Professional: For purposes of this chapter, a licensed mental health professional i s an individual who meets the requirements in the def inition of Licensed Independent Practitioner or who is licensed by the Tennessee Health Related Boards as a registered nurse, licensed practical nurse, or substance abuse counselor. (7) Medical Director: The physician designated to have overall responsibi lity for the provision of psychiatric care at the hospital. If the Medical Director is the treating physician, the chief officer must appoint an alternate for review purposes under this chapter. (8) Physical Restraint: Any method, including physical holdi ng or use of a mechanical device, material, or equipment attached or adjacent to an individual service recipient’s body, that he or she cannot easily remove, and that restricts freedom of movement or nor mal access to one’s body. There are two types of physical restraint: HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.02, continued) December, 2022 (Revised) 3 (a) Physical Holding: The use of staff body contact with a service recipient in order to restrict freedom of movement or normal access to one’s body. Physical holding does not include t he use of physical touch associated with prompting, comforting or assisting that does not prevent the individual service recipient’s freedom of movement or normal access to his or her body. In addition, physical holding does not include “physical escort” w hich means the temporary touching or holding of the hand, wrist, arm, shoulder or back for the purpose of inducing the individual to walk to a safe location. (b) Mechanical Restraint: For purposes of this chapter, the application of a mechanical device, material, or equipment attached or adjacent to the ser vice recipient’s body that the service recipient cannot easily remove and that restricts freedom of movement or normal access to the service recipient’s body. This includes the use of ambulatory restraint devices except as noted under the other exceptions below. For purposes of this chapter, physical restraint does not include the use of: 1. Any restrictive devices or manual methods employed by a law enforcement agent or other public safety officer to m aintain custody, detention, or public safety during the transport of an individual under the jurisdiction of the criminal justice system or juveniles with charges in the juvenile justice system; or 2. Restraints for medical immobilization, adaptive support, or medical protection; or 3. Restrictive devices administratively authorized to ensure the safety of the service recipient or others when an involuntary committed service recipient must be transported; or 4. Restrictive mechanical ambulatory devices used for the service recipient who: (i) Exhibits intractable behavior which is severely self -injurious or injurious to others, and (ii) Has not responded to usual and customary interventions, and (iii) Has restrictive mechanical ambulatory devices provided for and carried out in conformity with the service recipient’s behavioral plan in the individualized treatment plan. This behavioral plan must be re- evaluated at least every seven (7) days by the service recipient’s treatment team. Any use of restricti ve mechanical ambulatory devices must be reviewed by the Medical Director or designee every 24 hours. (9) PRN: An order which is written to allow a medication or treatment to be given on an as - needed basis. (10) Seclusion: See Isolation. (11) Service Recipient: For purposes of this chapter, an individual receiving inpatient mental health services in a hospital. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2 002. Amendments filed December 26, 2007; effective April 29, 2008. HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 December, 2022 (Revised) 1 0940-03-06-.03 PURPOSE OF ISOLATION OR RESTRAINT. (1) Isolation or restraint may be used only in emergency situations when necessary to assure the physical safety of the service recipient or a person nearby or to prevent significant destruction of property, if the process of destroying the property puts the service recipient or persons nearby in danger. Isolation or restraint may be used only when other less intrusive or restrictive meth ods have been ineffective or determined to be inappropriate. Isolation or restraint must be terminated when the behavior justifying its use no longer exists. (2) Isolation or restraint must not be impos ed in any form as a means of coercion, discipline, convenience or retaliation by staff. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.04 APPLICATION OF THIS CHAPTER. (1) This chapter applies to any hospital providing inpatient mental health services. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.05 POLICIES AND PROCEDURES. (1) Any hospital that provides inpatient mental health services and uses isolation or restraint must develop and employ policies and procedures that ens ure compliance with this chapter. Policies and procedures must identify approved techniques for the safe and appropriate application and removal of isolation and restraint, including physical holding. Policies and procedures must also identify approved d evices, materials, and/or equipment that is approved by the hospital for use as mechanical restraints. No policy or procedure may authorize a removal of clothing from a service recipient in conjunction with the use of isolation or restraint, other than that which is determined to place the service recipient or others at risk. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.06 INITIATION OF ISOLATION OR PHYSICAL RESTRAINT IN THE ABSENCE OF A LICENSED INDEPENDENT PRACTITIONER. (1) In the absence of a licensed independent practitioner, isolation or restraint may be initiated by a licensed mental health professional or by non- licensed mental health personnel with a minimum of a bachelor’s degree or two (2) years of full time equivalent experience in a mental health inpatient or residential treatment setting. Any staff member who initiates isolation or physical restraint must have documented training in compliance with this chapter. Staff who are authorized to take orders must immediately contact a licensed independent practitioner regarding authorization for the isolation or restraint. Chemical restr aint can be initiated only by order of a physician. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.07 AUTHORIZATION. (1) The use of isolation or physical restraint shall be authorized only by a licensed independent practitioner. Only a physician may authorize chemical restraint. All authorizations must specify isolation or the type of restraint that is authorized. If mechanical restraint is HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.07, continued) December, 2022 (Revised) 5 authorized, the authorization must specify the type of restraint device(s) to be utilized and the number of points of restraint. A new authorization is required if there is a change in the intervention utilized, including increasing the number of points of restraint or the application of additional restraint devices. If the use of isolation or restraint has been discontinued, it may be used again only with a new authorization, even if a previous order’s time limits have not yet expired. Isolation or restraint, including chemical restraint, cannot be ordered on a PRN basis. If the licensed independent practitioner who authorized the use of isolation, mechanical restraint, or physical holding restraint is not the service recipient’s treat ing physician, the treating physician shall be consulted as soon as possible. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.08 LENGTH OF AUTHORIZATION. (1) Each order for chemical restraint is limited to a single dose of medication to be administered at a single point in time. Each order for mechanical rest raint or isolation is limited to a maximum of four (4) hours for adults, two (2) hours for youth ages 9 through 17, and one (1) hour for children under age 9. Each order for physical holding for any age service recipient is limited to a maximum of thirty (30) minutes. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. Amendment filed December 26, 2007; effective April 29, 2008. 0940-03-06-.09 RENEWAL. (1) A licensed independent practitioner can renew the original order, including by verbal authorization, when a service recipient continues to need isolation or physical restraint beyond the time limits of the original order. Renewals must comply with the time limits specified in 0940-03-06-.08, for up to a total of 24 continuous hours. The hospital’s medical director or designee must then review the case and may authorize the licensed independent practitioner to renew the order for isolation or restraint in accordance with the time limits specified in 0940-03-06-.08 for up to a total of another 24 hours. If isolation or restraint is still indicated after the second 24 hour period, the hospital’s medical director must again review the case. This review process by the hospital’s medical director must occur at least every 24 hours as long as the service recipient is in isolation or physical restraint. A licensed independent practitioner must conduct a face- to-face assessment at least every 8 hours f or service recipients ages 18 and older and every 4 hours for service recipients ages 17 and younger. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.10 ASSESSMENTS. (1) The hospital must conduct the following types of assessments: (a) Risk Assessments: 1. Each service recipient must be assessed to ident ify individuals at risk of need for external controls such as isolation or restraint for his or her behavior. This assessment should include identification of any specific situations or issues, including cultural issues, that could potentially trigger behavior that might require the use of isolation or restraint. HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.10, continued) December, 2022 (Revised) 6 2. Each service recipient must be assessed to identify potential risks to the service recipient that might be associated with the use of isolation or restraint. The assessment shall include risks of physical/medical and psychologic al/emotional harm associated with the use of isolation or restraint, including risks related to cultural issues. 3. Risk assessments must be performed at admission by a licensed independent practitioner and updated by a licensed independent practitioner or other licensed mental health professional when there is significant change in mental status, behavior, or physical/medical condition. Risk assessments must be documented in the service recipient’s record. (b) Assessment of Need: 1. Prior to the use of isolation or restraint, the service recipient must have an assessment that supports that the use of isolation or restraint is necessary to assure the physical safety of the service recipient or a person nearby and that al l less restrictive interventions have been ineffective or determined to be inappropriate. 2. If the licensed independent practitioner authorizing the use of isolation or restraint is present at the time of the initiation of isolation or restraint, the lic ensed independent practitioner shal l document the assessment of need in the service recipient’s record. 3. If the use of isolation or restraint is initiated in the absence of a licensed independent practitioner, a licensed mental health professional shall document the assessment of need in the service recipient’s record at the time use of isolation or restraint is initiated. The licensed independent practitioner authorizing the use of isolation or restraint must document the rationale for the use of isolation or restraint in the service rec ipient’s record at the time the verbal/telephone order is authenticated. (c) Follow-up Assessment: 1. Within one (1) hour of the initiation of the use of isolation or physical restraint, a licensed independent practitioner or a registered nurse trained i n accordance with 0940-03-06-.19 must see and assess the service recipient’s condition. This assessment must be conducted regardless of the length of time the service recipient is in isolation or physical restraint. This assessment must be documented by th e licensed independent practitioner or registered nurse in the service recipient’s record. 2. When chemical restraint is used, a physician must see and assess the service recipient’s condition within one (1) hour of the administration of the medication used for chemical restraint. This assessment must be documented by the physician in the service recipient’s record. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. Amendment filed December 26, 2007; effective April 29, 2008. 0940-03-06-.11 BEHAVIORAL CRITERIA FOR RELEASE. (1) Behavioral criteria for release from isolatio n or physical restraint must be sp ecified by a licensed independent practitioner or a licensed mental health professional who can authorize HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.11, continued) December, 2022 (Revised) 7 initiation of isolation or physical restraint. The behavioral criteria must be documented in the service recipient’s record and must be communicated t o the service recipient as soon as possible during the isolation or physical restraint procedure. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.12 MONITORING AND ASSESSMENT OF CONTINUED NEED. (1) All results of monitoring must be documented in the service recipient’s record. (2) Assessment of continued need of isolation or physical restr aint: To continue the use of isolation or physical restraint, there must be ongoing assessment of continued need for isolation or restraint, including behavior which justifies the continued use of isolation or restraint and that the established behavioral criteria for release have not been met. Use of restraint or isolation must be monitored as follows: (3) Isolation. A service recipient in isolation must be monitored by staff trained in monitoring isolation. Monitoring activities must comply with the following: (a) The service recipient must be continuously monitored. For the first hour, monitoring must be by direct visual observation. After the first hour, monitoring may be via video camera WITH audio; if video monitoring is utilized a staff member must continuously monitor the video. (b) At intervals no greater than 15 minutes, staff must document visual observations of behavior regarding continued need for isolation, observation of respiration, untoward effects of isol ation and signs of distress. Such checks must be made via direct visual observation of the service recipient. Electronic monitoring for 15- minute checks is not allowed. (c) At intervals no greater than one (1) hour, the service recipient must be allowed t he opportunity to toilet and offer ed fluids. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient’s record. (d) At intervals no greater than one (1) hour, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an assessment of continued need for isolation. (e) Release from Isolation: The service recipient must be released from isolation when the need for isol ation no longer exists. Either a l icensed independent practitioner or other licensed mental health professional who has been authorized to initiate isolation under this chapter must document in the service recipient’s record an assessment of the service recipient’s behavior and mental and physical status at the time the service recipient is released from isolation. Documentation shall include the duration of the use of isolation. (4) Physical Restraint Monitoring. Monitoring activities must comply with the following: (a) Mechanical Restraint: A service recipient in mechanical restraint must be monitored by staff trained in the monitoring of mechanical restraint. Staff must remain in the immediate physical presence of and in the same room as a service recip ient who is in restraint. 1. At intervals no greater than 15 minutes, staff must document visual observations of behavior regarding the continued need for restraint; check and document the HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.12, continued) December, 2022 (Revised) 8 application of the restraint; respiration, untoward effects of res traint and signs of distress. 2. At intervals no greater than one (1) hour, the service recipient must be allowed the opportunity to toilet, offered fluids and be checked for range of motion. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient’s record. 3. At intervals no greater than one (1) hour, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an as sessment of continued need for mec hanical restraint. 4. Release from Mechanical Restraint: Mechanical restraints must be removed when the need for mechanical restraint no longer exists. Either a licensed independent practitioner or other licensed mental h ealth professional who has been authorized to initiate restraint under this chapter must document in the service recipient’s record an assessment of the service recipient’s behavior and mental and physical status at the time the service recipient is releas ed from restraint. Documentation s hall include the duration of the use of mechanical restraint. (b) Physical Holding: A service recipient in a physical hold must be monitored by staff trained in the monitoring of physical restraint. Monitoring activities must comply with the following: 1. A trained staff member who is an observer must be present at all times while a service recipient is in a physical hold. 2. At intervals no greater than 15 minutes, the staff member observing the physical hold must document visual observations of behavior regarding continued need for restraint; check and document application of the restraint, respiration, negative effects of restraint, and signs of distress. In addition, there must be an evaluation of the fatigue of the staff employing the hold. 3. At intervals no greater than one (1) hour, the service recipient must be allowed the opportunity to toilet and offered fluids, and be checked for range of motion. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient’s record. 4. At intervals no greater than thirty (30) minutes, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an assessment of continued need f or physical holding. 5. Release from Physical Holding: A service recipient must be released from physical holding when the need for physical holding no longer exists. Either a licensed independent practitioner or other li censed mental health professional who has been authorized to initiate restraint under this chapter must document in the service recipient’s record an assessment of the service recipient’s behavior and mental and physical status at the time the service reci pient is released from restraint. Documentation shall include the duration of the use of physical holding. (5) Chemical Restraint Monitoring: A service recipient who has been chemically restrained must be continuously observed by a staff member who is in the immediate physical presence and in the same room as the service recipient and who is trained to monitor chemical restraint. HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.12, continued) December, 2022 (Revised) 9 Particular attention must be given to safety issues such as preventing falls. Monitoring activities must comply with the following: (a) If intravenous medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within five (5) minutes of administration and at least every ten (10) minutes thereafter for the next th irty (30) minutes, if possible bas ed on the service recipient’s behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction and other issues as indicated. These examinations must be documented in the service recipient’s record. (b) If intramuscular medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within fifteen (15) minutes of administration and at least every fifteen (15) minutes for the first hour, if possible based on the service recipient’s behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction and other issues as indicated. These examinations must be documented in the s ervice recipient’s record. (c) If oral medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within thirty (30) minutes of the medication administr ation and every thirty (30) minutes for the first hour, if possible based on the service recipient’s behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction, and other issues as indicated. These examinations must be documented in the service recipient’s record. (d) In addition to the above monitoring requirements for chemical restraint, staff must document visual observations of the service recipient’s behavior at intervals no greater than fifteen (15) minutes. The ser vice recipient must be monitored for a time period defined by the prescriber as part of the chemical restraint order. If the prescriber does not define the time period for monitoring, the face- to-face observation shall continue for two (2) hours. (6) Concurrent Use: Concurrent use of physical restraint with chemical restraint must meet the monitoring requirements for both interventions. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. Amendments filed December 26, 2007; effective April 29, 2008. 0940-03-06-.13 LOCATION OF USE. (1) Isolation may be provided only in a clean, dry, comfortable location that does not contain anything with which the service recipient might harm self or others. Rooms used for isolation must be designed so that the entire room is vis ible from the isolation room’s observation window even if a video camera is used. Restraint must be imposed in an area as private as possible. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.14 TERMINATION. (1) Isolation or physical restraint must be terminated when the behavior justifying its use no longer exists or if the face-to-face assessments required under this chapter do not occur. Any HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.14, continued) December, 2022 (Revised) 10 threat to a service recipient’s physical health or emotional well being shall require immediate release. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.15 NOTIFICATION OF LEGAL SURROGATES. (1) The hospital must notify the parent/guardian or legal custodian, as appropriate, of an unemancipated child or the conservator, attorney -in-fact under a durab le power of attorney which authorizes mental health care, or surrogate decision- maker selected in accordance with TCA §§ 33-3-219 - 33-3-220 of an adult of the use of restraint or isolation as soon as possible but no later than 12 hours following initiation of the intervention. Unsuccessful attempts to notify must be documented in the service recipient's record. The parent/guardian, legal custodian, conservator, attorney -in-fact under a durable power of attorney which authorizes mental health care, or surrogate decision- maker, as appropriate, may modify the notice requirements in a written agreement. Such individuals must be provided the opportunity to participate in a discussion of the episode. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.16 NOTIFICATION OF FAMILY/SIGNIFICANT OTHER. (1) The hospital may notify other family members or signi ficant others as specified in 0940- 03- 06-.15 with a signed release by: the service recipient, or legal surrogate, or the authorization by a Treatment Revi ew Committee for an involuntarily committed service recipient or for a voluntary service recipient who lacks capacity to make decisions about release of information, and agreement by the family/significant other that he/she wishes to be notified. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.17 INTERNAL REVIEWS. (1) The hospital must provide and document three types of reviews: (a) Service Recipient Review. Unless clinically contraindicat ed, a licensed independent practitioner or mental health personnel who are authorized to initiate isolatio n or restraint must review the episode upon termination with the service recipient and with his or her legal surrogate, if available. The review shall occur as soon as possible following termination, but no later than twenty -four (24) hours following termi nation of isolation or restraint. The review must address the event, any identified reasons for the behavior, and strive to alleviate any trauma relat ed to the episode. This review must be documented in the service recipient’s record. If a review is clinic ally contraindicated, the rationale for the conclusion must be documented in the service recipient’s record. (b) Episode Review. Within twenty-four (24) hours of initiation of the isolation or restraint, there must be a staff review of the episode to ascertain the circumstances requiring the use and how it might be addressed differently. The staff review must include staff involved in the episode and, if possible, staff who were not party to the episode. The Chief Officer of the hospital or designee may, f or good cause, allow an exception to the review within twenty -four (24) hours. Under no circumstances may the review be concluded later than five (5) business days following the episode. The review must also address if there are needed changes to the servi ce recipient’s treatment plan, HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.17, continued) December, 2022 (Revised) 11 opportunities for performance improvements and address any need for alleviation of staff trauma associated with the episode. (c) Systematic Review: The hospital must develop and implement a process for systematic review of all isolation or restraint episodes and identification of trends of use of either isolation or restraint. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.18 PERFORMANCE IMPROVEMENT ACTIVITIES. (1) The hospital shall engage in on- going performance improvement activities that focus on the reduction of the use of isolation and restraint. Information obtained through the review processes (service recipient revi ew, episode review, and systematic review) shall be considered in the identification of specific performance improvement activities and in the evaluation of the effectiveness of the performance improvement activities. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. 0940-03-06-.19 TRAINING. (1) The hospital must identify specific staff, based on their j ob responsibilities, who are involved in the use of isolation or restraint and must assure that they are adequately trained and are competent in the following areas: (a) Medical/physical and psychological risk factors associated with the use of isolation and restraint, (b) Prevention of and early intervention for assaultive, self-injurious behavior, (c) Specific techniques approved by the hospital for the safe and appropriate application and removal of isolation and restraint, including physical holding, (d) Use of specific devices, materials, and/or equipment approved by the hospital f or use as mechanical restraints, (e) Procedures to address problems associated with the use of restraints, (f) Hospital policies and procedures regarding isolation and r estraint that are in compliance with this chapter, (g) Needs and behaviors of the population served, (h) Legal issues, and (i) Applicable state and federal law and regulations. (2) The hospital must identify specific staff that must be trained before assuming direct care responsibilities. All other identified staff must be trained within six (6) weeks of initial employment. The hospital must provide annual refresher training on all of the above training elements. (3) If diploma, associate, or baccalaur eate prepared registered nurses are responsible for the assessment of the service rec ipient’s condition within one (1) hour of the initiation of isolation HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 (Rule 0940-03-06-.19, continued) December, 2022 (Revised) 12 or physical restraint, the hospital must identify specific registered nurses with this responsibility and must assure that they are adequately trained and are competent in the following areas: (a) Anticipation of adverse medical/physical and psychological service recipient response(s) which had been identified in the risk assessments required in 0940- 03-06- .10; (b) Anticipation of adverse medical/physical and psychological response(s) based upon the current condition of the service recipient; (c) Identification and management of adverse medical/physical and psychological response(s) resulting from the use of isolation or physical restraint; and (d) Identification and utilization of the service recipient’s mental preparedness to self regulate and objectively appraise the isolation or physical restraint event. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative Hi story: Original rule filed October 3, 2002; effective December 17, 2002. Amendment filed December 26, 2007; effective April 29, 2007. 0940-03-06-.20 REPORTING. (1) Each hospital that uses isolation or restraint must annually report information specified by TDMHSAS to the Commissioner of TDMHSAS. TDMHSAS shall establish reporting guidelines and deadlines necessary to assure uniform reporting of minimum aggregated isolation and restraint data by each hospital. (2) Any hospital using isolation or restraint mus t notify the Commissioner of TDMHSAS of any death that occurs while a service recipient is restrained or isolated, or where it is reasonable to assume that a service r ecipient’s death is attributable to, or results from, restraint or isolation. The hospital must report such deaths by the next business day following the service recipient’s death. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed October 3, 2002; effective December 17, 2002. Administrative corrections made to agency names in December 2022 pursuant to Public Chapter 575 of 2012.