Section R9-10-225. Psychiatric Services

A.      An administrator of a hospital that contains an organized psy- chiatric services unit or a special hospital licensed to provide psychiatric services shall ensure that in the organized psychiat- ric unit or special hospital:

1.        Psychiatric services are provided under the direction of a medical staff member;

2.        An inpatient admitted to the organized psychiatric ser- vices unit or special hospital has a principal diagnosis of a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor;

3.        Except in an emergency, a patient receives a nursing assessment before treatment for the patient is initiated;

4.        An individual whose medical needs cannot be met while the individual is an inpatient in an organized psychiatric services unit or a special hospital is not admitted to or is transferred out of the organized psychiatric services unit or special hospital;

5.        Policies and procedures for the organized psychiatric ser- vices unit or special hospital are established, documented, and implemented that:

a.         Establish qualifications for medical staff members and personnel members who provide clinical over- sight to behavioral health technicians;

b.        Establish the process for patient assessment, includ- ing identification of a patient’s medical conditions and criteria for the on-going monitoring of any iden- tified medical condition;

c.         Establish the process for developing and implement- ing a patient's care plan including:

i.         Obtaining the patient's or the patient's represen- tative's participation in the development of the patient's care plan;

ii.        Ensuring that the patient is informed of the modality, frequency, and duration of any treat- ments that are included in the patient's care plan;

iii.      Informing the patient that the patient has the right to refuse any treatment;

iv.       Updating the patient's care plan and informing the patient of any changes to the patient's care plan; and

v.        Documenting the actions in subsection (A)(5)(c)(i) through (iv) in the patient's medical record;

d.        Establish the process for warning an identified or identifiable individual, as described in A.R.S. § 36-

517.02 (B) through (C), if a patient communicates to a medical staff member or personnel member a threat of imminent serious physical harm or death to the individual and the patient has the apparent intent and ability to carry out the threat;

e.         Establish the criteria for determining when an inpa- tient’s absence is unauthorized, including whether the inpatient:

i.         Was admitted under A.R.S. Title 36, Chapter 5, Articles 1, 2, or 3;

ii.        Is absent against medical advice; or

iii.      Is under 18 years of age;

f.         Identify each type of restraint and seclusion used in the organized psychiatric  services unit or special hospital and include for each type of restraint and seclusion used:

i.         The qualifications of a medical staff member or personnel member who can:

(1)     Order the restraint or seclusion,

(2)     Place a patient in the restraint or seclusion,

(3)     Monitor a patient in the restraint or seclu- sion,

(4)     Evaluate a patient’s physical and psycho- logical well-being after being placed in the restraint or seclusion and when released from the restraint or seclusion, or

(5)     Renew the order for restraint or seclusion;

ii.        On-going training requirements for a medical staff member or personnel member who has direct patient contact while the patient is in a restraint or in seclusion; and

iii.      Criteria for monitoring and assessing a patient including:

(1)     Frequencies of monitoring and assessment based on a patient's condition, cognitive status, situational factors, and risks associ- ated with the specific restraint or seclu- sion;

(2)     For the renewal of an order for restraint or seclusion, whether an assessment is required before the order is renewed and, if an assessment is required, who may conduct the assessment;

(3)     Assessment content, which may include, depending on a patient's condition, the patient's vital signs, respiration, circula- tion, hydration needs, elimination needs, level of distress and agitation, mental sta- tus, cognitive functioning, neurological functioning, and skin integrity;

(4)     If a mechanical restraint is used, how often the mechanical restraint is monitored or loosened; and

(5)     A process for meeting a patient's nutri- tional needs and elimination needs;

g.        Establish the criteria and procedures for renewing an order for restraint or seclusion;

h.        Establish procedures for internal review of the use of restraint or seclusion;

i.         Establish requirements for notifying the parent or guardian of a patient who is under 18 years of age and who is restrained or secluded; and

j.         Establish medical record and personnel record docu- mentation requirements for restraint and seclusion, if applicable;

6.        If time out is used in the organized psychiatric services unit or special hospital, a time out:

a.         Takes place in an area that is unlocked, lighted, quiet, and private;

b.        Does not take place in the room approved for seclu- sion by the Department under R9-10-104;

c.         Is time-limited and does not exceed two hours per incident or four hours per day;

d.        Does not result in a patient's missing a meal if the patient is in time out at mealtime;

e.         Includes monitoring of the patient by a medical staff member or personnel member at least once every 15 minutes to ensure the patient's health, safety, and welfare and to determine if the patient is ready to leave time out; and

f.         Is documented in the patient's medical record, to include:

i.         The date of the time out,

ii.        The reason for the time out,

iii.      The duration of the time out, and

iv.       The action planned and taken to address the reason for the time out;

7.        Restraint or seclusion is:

a.         Not used as a means of coercion, discipline, conve- nience, or retaliation;

b.        Only used when all of the following conditions are met:

i.         Except as provided in subsection (A)(8), after obtaining an order for the restraint or seclusion;

ii.        For the management of a patient’s aggressive, violent, or self-destructive behavior;

iii.      When less restrictive interventions have been determined to be ineffective; and

iv.       To ensure the immediate physical safety of the patient, to prevent imminent harm to the patient or another individual, or to stop physical harm to another individual; and

c.         Discontinued at the earliest possible time;

8.        If as a result of a patient’s aggressive, violent, or self- destructive behavior, harm to the patient or another indi- vidual is imminent or the patient or another individual is being physically harmed, a personnel member:

a.         May initiate an emergency application of restraint or seclusion for the patient before obtaining an order for the restraint or seclusion, and

b.        Obtains an order for the restraint or seclusion of the patient during the emergency application of the restraint or seclusion;

9.        Restraint or seclusion is:

a.         Only ordered by a physician or a registered nurse practitioner, and

b.        Not written as a standing order or on an as-needed basis;

10.     An order for restraint or seclusion includes:

a.         The name of the individual ordering the restraint or seclusion;

b.        The date and time that the restraint or seclusion was ordered;

c.         The specific restraint or seclusion ordered;

d.        If a drug is ordered as a chemical restraint,  the drug’s name, strength, dosage, and route of adminis- tration;

e.         The specific criteria for release from restraint or seclusion without an additional order; and

f.         The maximum duration authorized for the restraint or seclusion;

11.     An order for restraint or seclusion is limited to the dura- tion of the emergency situation and does not exceed:

a.         Four continuous hours for a patient who is 18 years of age or older,

b.        Two continuous hours for a patient who is between the ages of nine and 17 years of age, or

c.         One continuous hour for a patient who is younger than nine years of age;

12.     If restraint and seclusion are used on a patient simultane- ously, the patient receives continuous:

a.         Face-to-face monitoring by a medical staff member or personnel member, or

b.        Video and audio monitoring by a medical staff mem- ber or personnel member who is in close proximity to the patient;

13.     If an order for restraint or seclusion of a patient is not pro- vided by a medical practitioner coordinating the patient’s medical services, the medical practitioner is notified as soon as possible;

14.     A medical staff member or personnel member does not participate in restraint or seclusion, monitor a patient during restraint or seclusion, or evaluate a patient after restraint or seclusion until the medical staff member or personnel member completes education and training that:

a.         Includes:

i.         Techniques to identify medical staff member, personnel member, and patient behaviors; events; and environmental factors that may trigger circumstances that require restraint or seclusion;

ii.        The use of nonphysical intervention skills, such as de-escalation, mediation, conflict resolu- tion, active listening, and verbal and observa- tional methods;

iii.      Techniques for identifying the least restrictive intervention based on an assessment of the patient’s medical or behavioral health condi- tion;

iv.       The safe use of restraint and the safe use of seclusion, including training in how to recog- nize and respond to signs of physical and psy- chological distress in a patient who is restrained or secluded;

v.        Clinical identification of specific behavioral changes that indicate that the restraint or seclu- sion is no longer necessary;

vi.       Monitoring and assessing a patient while the patient is in restraint or seclusion according to policies and procedures; and

vii.     Training exercises in which medical staff mem- bers and personnel members successfully demonstrate the techniques that the medical staff members and personnel members have learned for managing emergency situations; and

b.        Is provided by individuals qualified according to policies and procedures;

15.     When a patient is placed in restraint or seclusion:

a.         The restraint or seclusion is conducted according to policies and procedures;

b.        The restraint or seclusion is proportionate and appropriate to the severity of the patient’s behavior and the patient’s:

i.         Chronological and developmental age;

ii.        Size;

iii.      Gender;

iv.       Physical condition;

v.        Medical condition;

vi.       Psychiatric condition; and

vii.     Personal history, including any history of phys- ical or sexual abuse;

c.         The physician or registered nurse practitioner who ordered the restraint or seclusion is available for consultation throughout the duration of the restraint or seclusion;

d.        A patient is monitored and assessed according to policies and procedures;

e.         A physician or other health professional authorized by policies and procedures assesses the patient within one hour after the patient is placed in the restraint or seclusion and determines:

i.         The patient’s current behavior,

ii.        The patient’s reaction to the restraint or seclu- sion used,

iii.      The patient’s medical and behavioral condition, and

iv.       Whether to continue or terminate the restraint or seclusion;

f.         The patient is given the opportunity:

i.         To eat during mealtime, and

ii.        To use the toilet; and

g.        The restraint or seclusion is discontinued at the earli- est possible time, regardless of the length of time identified in the order;

16.     If a patient is placed in seclusion, the room used for seclusion:

a.         Is approved for use as a seclusion room by the Department under R9-10-104;

b.        Is not used as a patient's bedroom or a sleeping area;

c.         Allows full view of the patient in all areas of the room;

d.        Is free of hazards, such as unprotected light fixtures or electrical outlets;

e.         Contains at least 60 square feet of floor space; and

f.         Except as provided in subsection (A)(17), contains a non-adjustable bed that:

i.         Consists of a mattress on a solid platform that is:

(1)     Constructed of a durable, non-hazardous material; and

(2)     Raised off of the floor;

ii.        Does not have wire springs or a storage drawer; and

iii.      Is securely anchored in place;

17.     If a room used for seclusion does not contain a non- adjustable bed required in subsection (A)(16)(f):

a.         A piece of equipment is available for use in the room used for seclusion that:

i.         Is commercially manufactured to safely and humanely restrain a patient’s body;

ii.        Provides support to the trunk and head of a patient’s body;

iii.      Provides restraint to the trunk of a patient’s body;

iv.       Is able to restrict movement of a patient’s arms, legs, trunk, and head;

v.        Allows a patient’s body to recline; and

vi.       Does not inflict harm on a patient’s body; and

b.        Documentation of the manufacturer’s specifications for the piece of equipment in subsection (A)(17)(a) is maintained;

18.     A seclusion room may be used for services or activities other than seclusion if:

a.         A sign stating the service or activity scheduled or being provided in the room is conspicuously posted outside the room;

b.        No permanent equipment other than the bed required in subsection (A)(16)(f) is in the room;

c.         Policies and procedures are established, docu- mented, and implemented that:

i.         Delineate which services or activities other than seclusion may be provided in the room,

ii.        List what types of equipment or supplies may be placed in the room for the delineated ser- vices, and

iii.      Provide for the prompt removal of equipment and supplies from the room before the room is used for seclusion; and

d.        The sign required in subsection (A)(18)(a) and equipment and supplies in the room, other than the

bed required in subsection (A)(16)(f), are removed before a patient is placed in seclusion in the room;

19.     A medical staff member or personnel member documents the following information in a patient’s medical record before the end of the shift in which the patient is placed in restraint or seclusion or, if the patient’s restraint or seclu- sion does not end during the shift in which it began, during the shift in which the patient’s restraint or seclu- sion ends:

a.         The emergency situation that required the patient to be restrained or put in seclusion;

b.        The times the patient’s restraint or seclusion actually began and ended;

c.         The time of the face-to-face assessment required in subsection (A)(12)(a);

d.        The monitoring required in subsection (A)(12)(b) or (15)(d), as applicable;

e.         The times the patient was given the opportunity to eat or use the toilet according to subsection (A)(15)(f); and

f.         The names of the medical staff members and person- nel members with direct patient contact while the patient was in the restraint or seclusion; and

20.     If an emergency situation continues beyond the time limit of an order for restraint or seclusion, the order is renewed according to policies and procedures.

B.       An administrator of a hospital that provides opioid treatment services to an outpatient shall comply with the requirements in R9-10-1020.

Historical Note

Adopted effective February 23, 1979 (Supp. 79-1). Sec- tion repealed; new Section made by final rulemaking at 8

A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Section R9-10-225 renumbered to R9-10-227; new Sec-

tion R9-10-225 renumbered from R9-10-224 and amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).