Mental Health:

Improper Restraint or Seclusion Use Places People at Risk

HEHS-99-176: Published: Sep 7, 1999. Publicly Released: Oct 1, 1999.

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Pursuant to a congressional request, GAO provided information on inpatient and residential treatment facilities' use of restraints or seclusion as a means of treating mental patients, focusing on the: (1) dangers of restraint and seclusion, the extent to which restraint and seclusion are used in inpatient and residential treatment facilities for individuals with mental illness or mental retardation, and the number of related injuries and deaths; (2) federal and state policies that govern the use of restraint and seclusion in inpatient or residential treatment facilities for individuals with mental illness or mental retardation; and (3) experiences of states that have instituted regulations and reporting requirements to address the use of restraint and seclusion.

GAO noted that: (1) improper restraint and seclusion can be dangerous to both people receiving treatment and staff, but the full extent of related injuries and deaths is unknown; (2) there is no comprehensive reporting system to track such injuries and deaths or the rates of restraint and seclusion use by facility; (3) GAO's telephone survey of 51 state Protection and Advocacy agencies (P&A) found that only 15 states have any systematic reporting to alert these agencies to any deaths that occur among individuals in residential treatment settings; (4) even these reporting systems are not comprehensive, because most agencies that receive reports get them only from state facilities; (5) on the basis of the partial information available from these 51 agencies, GAO identified 24 deaths associated with restraint or seclusion during fiscal year 1998; (6) because reporting is so fragmentary, GAO believes many more deaths related to restraint or seclusion may occur; (7) data on use of restraint and seclusion are also fragmentary because most facilities are not required to report these data to oversight agencies; (8) federal and state regulations governing restraint and seclusion for individuals with mental illness and mental retardation are inconsistent across types of facilities; (9) the federal government regulates the use of restraint and seclusion in nursing homes and state Intermediate Care Facilities for the Mentally Retarded, but until recently, no federal regulations governed their use in other facilities, such as psychiatric hospitals, residential treatment centers for children, or community group homes; (10) in July 1999, the Health Care Financing Administration (HCFA) issued an interim final rule with revised Medicare conditions of participation for hospitals that address restraint and seclusion use; (11) although this is a positive first step, people in residential treatment centers and group homes participating in the Medicaid Home and Community-Based Waiver program have limited federal protection; (12) while some states have regulations in place governing the use of restraint and seclusion, often these regulations do not apply to privately operated facilities; and (13) on the basis of the experience of several states, having regulatory protections and reporting requirements can reduce the use of restraint and seclusion and improve safety for patients and staff.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: CMS currently has regulations governing the use of restraint and seclusion in hospitals, nursing homes, ICF/MRs, and psychiatric residential treatment facilities. However, in its final rule on Hospital Patient Rights, published December 8, 2006 (71 FR 71378), CMS indicated that it would not develop identical standards across care settings for patient protections regarding the use of restraint and seclusion.

    Recommendation: The Administrator, HCFA, should ensure that patient protections regarding the use of restraint and seclusion are consistent by extending to all individuals receiving treatment in Medicare- and Medicaid-funded facilities, including those in facilities covered under a waiver program, protections such as those in place for these individuals in hospitals, nursing homes, and Intermediate Care Facilities for the Mentally Retarded. These protections include a right to be free from any physical or chemical restraints or seclusion imposed for the purposes of coercion, discipline, or staff convenience and to receive active treatment to reduce dependency on chemical or physical restraint or seclusion. Restraint or seclusion would be used only for medical or surgical care, as part of an individual behavioral teaching program that is intended to lead to a less restrictive means of managing and eliminating the behavior for which the restraint is applied, or in emergency situations when necessary to ensure the individual's or others' physical safety and after less restrictive interventions have been ineffective to protect the individual or others from harm.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Implemented

    Comments: In a September 1999 report, we recommended that any hospital or residential facility, as a condition of receiving Medicare or Medicaid payments, report to the state licensing authority and protection and advocacy organization on all deaths and serious injuries of individuals with mental illness or mental retardation in their facilities and indicate whether restraint or seclusion was used during or immediately before the death or injury. The Patients Rights Final Rule, published December 8, 2006 (71 FR 71378), expanded hospital reporting requirements and specifies that hospitals must report the following information to the Centers for Medicare Services: each death that occurs while a patient is in restraint or seclusion; each death that occurs within 24 hours after a patient has been removed from restraint or seclusion; and each death known to the hospital that occurs within one week after restraint or seclusion, where it is reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to the death. The interim final rule regarding restraint and seclusion in psychiatric residential treatment facilities requires applicable facilities to: (1) notify residents and/or parents or legal guardians of the facility's restraint policy; (2) report all deaths of residents to CMS; and (3) report all deaths, serious injuries, and attempted suicides to the State Medicaid Agency and the State-designated Protection and Advocacy System.

    Recommendation: The Administrator, HCFA, should mandate that any hospital or residential facility that treats individuals with mental illness or mental retardation, as a requirement for receiving Medicare and Medicaid funds, using a uniform reporting protocol, report promptly to the state licensing body and the appropriate P&A all deaths and serious injuries among individuals with mental illness or mental retardation to facilitate effective investigation, and indicate whether restraint or seclusion was used during or immediately before death or injury.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  3. Status: Closed - Not Implemented

    Comments: The Patients Rights for Conditions of Participation for hospitals mandates that the use of restraints and seclusion will be documented on the patient's record, with the needed documentation elements listed, but does not require reporting on rates of use to CMS (formerly HCFA). The regulation regarding restraint and seclusion in psychiatric residential treatment facilities (PRTFs) requires PRTFs to submit an attestation of compliance to the rule to its State Medicaid Agency, which the state survey agency is required to validate for 20 percent of PRTFs annually. CMS developed procedures for state agencies to follow to review facilities' use of restraint and seclusion.

    Recommendation: The Administrator, HCFA, should mandate that any hospital or residential facility that treats individuals with mental illness or mental retardation, as a requirement for receiving Medicare and Medicaid funds, maintain records to document the facility's use of restraint and seclusion and report rates of use to HCFA periodically, using common definitions.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  4. Status: Closed - Implemented

    Comments: The Patients Rights Final Rule published December 8, 2006 (71 FR 71378), added a new standard that required hospitals to train staff. Hospital staff must be able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing any of these actions as part of orientation, and subsequently, on a periodic basis consistent with hospital policy. Hospitals must also provide education and training so that staff can demonstrate knowledge of how to identify behaviors or events that trigger episodes which might require use of restraints and seclusion, use of non-physical intervention skills, choosing the least restrictive intervention, how to recognize and respond to signs of physical and psychological distress, such as positional asphyxia, clinical identification of changes that indicate restraint or seclusion is no longer necessary, monitoring the physical and psychological well-being of the patient, and the use of first aid techniques, including certification in the use of cardiopulmonary resuscitation. The PRTF rule requires that the facility provide and document ongoing education and training of staff in the safe and appropriate use of restraint and seclusion, and in the use of non-intrusive behavior modification techniques. CMS will be involved in further rule making to implement the Children's Health Act of 2000, which may address this issue in other care settings. The Unified Agenda of April 2007, lists a rule in the proposed stage on the use of restraint and seclusion in Medicare and Medicaid participating facilities that provide inpatient or residential care (0938-AL-26). This proposed rule is estimated to be issued in 2007. The rule would establish common terminology and basic expectations for the use of restraints and seclusion for health care facilities that furnish inpatient or residential care and receive Medicare or Medicaid funding.

    Recommendation: The Administrator, HCFA, should mandate that any hospital or residential facility that treats individuals with mental illness or mental retardation, as a requirement for receiving Medicare and Medicaid funds, ensure that staff regularly receive training and refresher courses in safe methods to handle agitated or potentially violent individuals, including alternative methods to restraint or seclusion, and document staffs' receipt of the training.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

 

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