Tenn. Comp. R. & Regs. 0940-03-06-.12 - MONITORING AND ASSESSMENT OF CONTINUED NEED

(1) All results of monitoring must be documented in the service recipient's record.

(2) Assessment of continued need of isolation or physical restraint: To continue the use of isolation or physical restraint, there must be ongoing assessment of continued need for isolation or restraint, including behavior which justifies the continued use of isolation or restraint and that the established behavioral criteria for release have not been met. Use of restraint or isolation must be monitored as follows:

(3) Isolation. A service recipient in isolation must be monitored by staff trained in monitoring isolation. Monitoring activities must comply with the following:

(a) The service recipient must be continuously monitored. For the first hour, monitoring must be by direct visual observation. After the first hour, monitoring may be via video camera WITH audio; if video monitoring is utilized a staff member must continuously monitor the video.

(b) At intervals no greater than 15 minutes, staff must document visual observations of behavior regarding continued need for isolation, observation of respiration, untoward effects of isolation and signs of distress. Such checks must be made via direct visual observation of the service recipient. Electronic monitoring for 15-minute checks is not allowed.

(c) At intervals no greater than one (1) hour, the service recipient must be allowed the opportunity to toilet and offered fluids. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient's record.

(d) At intervals no greater than one (1) hour, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an assessment of continued need for isolation.

(e) Release from Isolation: The service recipient must be released from isolation when the need for isolation no longer exists. Either a licensed independent practitioner or other licensed mental health professional who has been authorized to initiate isolation under this chapter must document in the service recipient's record an assessment of the service recipient's behavior and mental and physical status at the time the service recipient is released from isolation. Documentation shall include the duration of the use of isolation.

(4) Physical Restraint Monitoring. Monitoring activities must comply with the following:

(a) Mechanical Restraint: A service recipient in mechanical restraint must be monitored by staff trained in the monitoring of mechanical restraint. Staff must remain in the immediate physical presence of and in the same room as a service recipient who is in restraint.

1. At intervals no greater than 15 minutes, staff must document visual observations of behavior regarding the continued need for restraint; check and document the application of the restraint; respiration, untoward effects of restraint and signs of distress.

2. At intervals no greater than one (1) hour, the service recipient must be allowed the opportunity to toilet, offered fluids and be checked for range of motion. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient's record.

3. At intervals no greater than one (1) hour, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an assessment of continued need for mechanical restraint.

4. Release from Mechanical Restraint: Mechanical restraints must be removed when the need for mechanical restraint no longer exists. Either a licensed independent practitioner or other licensed mental health professional who has been authorized to initiate restraint under this chapter must document in the service recipient's record an assessment of the service recipient's behavior and mental and physical status at the time the service recipient is released from restraint. Documentation shall include the duration of the use of mechanical restraint.

(b) Physical Holding: A service recipient in a physical hold must be monitored by staff trained in the monitoring of physical restraint. Monitoring activities must comply with the following:

1. A trained staff member who is an observer must be present at all times while a service recipient is in a physical hold.

2. At intervals no greater than 15 minutes, the staff member observing the physical hold must document visual observations of behavior regarding continued need for restraint; check and document application of the restraint, respiration, negative effects of restraint, and signs of distress. In addition, there must be an evaluation of the fatigue of the staff employing the hold.

3. At intervals no greater than one (1) hour, the service recipient must be allowed the opportunity to toilet and offered fluids, and be checked for range of motion. Nourishment must be offered at routine meal and snack times. This must be documented in the service recipient's record.

4. At intervals no greater than thirty (30) minutes, a licensed independent practitioner or other licensed mental health professional authorized to initiate isolation under this chapter must document an assessment of continued need for physical holding.

5. Release from Physical Holding: A service recipient must be released from physical holding when the need for physical holding no longer exists. Either a licensed independent practitioner or other licensed mental health professional who has been authorized to initiate restraint under this chapter must document in the service recipient's record an assessment of the service recipient's behavior and mental and physical status at the time the service recipient is released from restraint. Documentation shall include the duration of the use of physical holding.

(5) Chemical Restraint Monitoring: A service recipient who has been chemically restrained must be continuously observed by a staff member who is in the immediate physical presence and in the same room as the service recipient and who is trained to monitor chemical restraint. Particular attention must be given to safety issues such as preventing falls. Monitoring activities must comply with the following:

(a) If intravenous medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within five (5) minutes of administration and at least every ten (10) minutes thereafter for the next thirty (30) minutes, if possible based on the service recipient's behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction and other issues as indicated. These examinations must be documented in the service recipient's record.

(b) If intramuscular medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within fifteen (15) minutes of administration and at least every fifteen (15) minutes for the first hour, if possible based on the service recipient's behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction and other issues as indicated. These examinations must be documented in the service recipient's record.

(c) If oral medication is administered, the service recipient must be examined by either a physician, licensed nurse or physician assistant within thirty (30) minutes of the medication administration and every thirty (30) minutes for the first hour, if possible based on the service recipient's behavior, for mental status, blood pressure, pulse, respiration, signs of distress, signs and symptoms of adverse drug reaction, and other issues as indicated. These examinations must be documented in the service recipient's record.

(d) In addition to the above monitoring requirements for chemical restraint, staff must document visual observations of the service recipient's behavior at intervals no greater than fifteen (15) minutes. The service recipient must be monitored for a time period defined by the prescriber as part of the chemical restraint order. If the prescriber does not define the time period for monitoring, the face-to-face observation shall continue for two (2) hours.

(6) Concurrent Use: Concurrent use of physical restraint with chemical restraint must meet the monitoring requirements for both interventions.

Notes

Tenn. Comp. R. & Regs. 0940-03-06-.12

Original rule filed October 3, 2002; effective December 17, 2002. Amendments filed December 26, 2007; effective April 29, 2008.

Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-120, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302.