Sec. 10.21.12.08. Clinical Interventions During Restraint

A. Regardless of the physical setting in which the patient is placed, at a minimum, one staff member shall be assigned continuously while the patient is in a category I restraint.

B. While the patient is restrained, in order to provide appropriate clinical care, at a minimum, staff clinically trained to do so shall:

(1) Keep the patient in full view at all times;

(2) Protect the patient from harm by others;

(3) Closely observe the patient at least every 15 minutes, and document each observation by the observer;

(4) Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, at least hourly, make and document personal contact with the patient for the purpose of:

(a) Determining if the patient has any special needs which need attention;

(b) Checking circulation of the extremities restrained;

(c) Adjusting the restraint; and

(d) Realigning the body or massaging the extremities restrained, or both;

(5) Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, offer or provide the following:

(a) Full range of motion, every 2 hours;

(b) Toilet facilities, at least every 2 hours;

(c) Bathing and oral hygiene, at least once during a 24-hour period;

(d) Meals, at the regularly scheduled hours and under the supervision of nursing personnel; and

(e) Fluids, at least every 2 hours; and

(6) As clinically indicated, record temperature, pulse, blood pressure, and respirations.

C. At least once every 2 hours, a physician or registered nurse shall assess the appropriateness of continuing the restraint and document the factors supporting the assessment in the patient's medical record.

D. Unless circumstances suggest a medical problem may exist, staff may not disrupt a patient's sleep during the night to implement the clinical procedures described in §§B and C of this regulation.