NAC449.3628. Protection of patients; use of physical restraints.

     1. A governing body shall develop and carry out policies and procedures that prevent and prohibit:

     (a) Verbal, sexual, physical and mental abuse of patients; and

     (b) The involuntary seclusion of a patient without clinical justification for that seclusion.

     2. The governing body shall develop and carry out policies and procedures that prevent and prohibit neglect and misappropriation of the personal property of a patient.

     3. The governing body shall develop policies and procedures for the identification and investigation of neglect and abuse of patients.

     4. The governing body shall develop and carry out organizational policies and procedures that limit the use of physical restraints on patients to only those situations in which the use of physical restraints is appropriate and for which there is adequate clinical justification.

     5. The governing body shall ensure that the use of any physical restraints on a patient is initiated only pursuant to a physician’s order or protocols approved by the medical staff and the hospital administration.

     6. If the use of physical restraints is permitted pursuant to approved protocols, the approved protocols must include:

     (a) A thorough assessment of the patient before the use of physical restraints is initiated;

     (b) A provision that requires the initiation of the use of the physical restraints by a registered nurse or other authorized person according to hospital policy;

     (c) A provision for notifying the physician within 12 hours after the use of the physical restraints is initiated;

     (d) A requirement that a verbal or written order of the physician be obtained and entered into the medical record of the patient; and

     (e) A requirement that the continued use of physical restraints beyond the first 24 hours be authorized by the physician through the renewal of the original order. The issuance of an order for the continued use of physical restraints on a patient must occur no less often than once each calendar day.

     7. Organizational policies and procedures, protocols, physician’s orders and the individual needs of a patient must be used to establish the frequency, nature and extent of monitoring of a patient upon whom physical restraints are being used.

     8. The hospital shall have a process for quality improvement to identify appropriate opportunities for reducing the use of physical restraints. The process for quality improvement must include areas for measurement and assessment to identify opportunities to reduce the risks associated with the use of physical restraints through the introduction of preventive strategies, innovative alternatives to the use of physical restraints and improvements to the process of using physical restraints.

     (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)