Internal Reviews

(1) The hospital must provide and document three types of reviews: (a) Service Recipient Review. Unless clinically contraindicated, a licensed independent practitioner or mental health personnel who are authorized to initiate isolation or restraint must review the episode upon termination with the service recipient and with his or her legal surrogate, if available. The review shall occur as soon as possible following termination, but no later than twenty-four (24) hours following termination of isolation or restraint. The review must address the event, any identified reasons for the behavior, and strive to alleviate any trauma related to the episode. This review must be documented in the service recipient’s record. If a review is clinically contraindicated, the rationale for the conclusion must be documented in the service recipient’s record. (b) Episode Review. Within twenty-four (24) hours of initiation of the isolation or restraint, there must be a staff review of the episode to ascertain the circumstances requiring the use and how it might be addressed differently. The staff review must include staff involved in the episode and, if possible, staff who were not party to the episode. The Chief Officer of the hospital or designee may, for good cause, allow an exception to the review within twenty-four (24) hours. Under no circumstances may the review be concluded later than five (5) business days following the episode. The review must also address if there are needed changes to the service recipient’s treatment plan, HOSPITAL ISOLATION AND RESTRAINT CHAPTER 0940-03-06 opportunities for performance improvements and address any need for alleviation of staff trauma associated with the episode. (c) Systematic Review: The hospital must develop and implement a process for systematic review of all isolation or restraint episodes and identification of trends of use of either isolation or restraint.