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
|Health Care Financing Administration||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.|
|Health Care Financing Administration||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.|
|Health Care Financing Administration||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.|
|Health Care Financing Administration||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.|