Sec. 10.21.13.10. Quality Assurance

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

B. The physician involved in the seclusion 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 seclusion to assure that the standards maintained by the facility are, at a minimum, consistent with this chapter.

D. Staff who implement orders for seclusion:

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

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

E. Standards for a Seclusion Room.

(1) The CEO or the CEO's designee is responsible for assuring that the seclusion room or rooms in the facility are maintained in accordance with acceptable standards for hygiene and safety.

(2) Staff shall ensure that each seclusion room:

(a) Unless clinically contraindicated and the record reflects that assessment, has a mattress provided;

(b) At the beginning of each shift, is inspected and maintained for proper temperature, ventilation, safety, lighting, sanitation, and freedom from dangerous conditions; and

(c) Is fitted with a means of observation that affords staff a view of the entire room and permits clinical staff periodically to observe the patient.

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