Sec. 10.21.12.12. Quality Assurance

A. The clinical director or the clinical director's designee shall review daily all uses of restraint and investigate unusual or possibly unwarranted patterns of use.

B. The physician involved in the restraint may not function in the capacity outlined in §A of this regulation.

C. A facility shall identify a committee to review periodically, but not less than quarterly, the use of restraint to assure that the standards maintained by the facility are, at a minimum, consistent with this chapter.

D. Staff who implement orders for restraint:

(1) Shall have documented annual training in the proper use of restraint including training for special populations which include, but are not limited to, children and the elderly; and

(2) May not implement orders for restraint until trained by the facility to do so unless, in an emergency situation, the safety of the patient or others is threatened.

E. The facility's chief executive officer or the chief executive officer's designee is responsible for assuring that the restraint devices used in that facility are maintained in accordance with acceptable standards for hygiene and safety.

F. If seclusion is used in conjunction with restraint, staff shall comply with regulations for the use of seclusion.