Assessment

(1) Risk assessments must be completed at admission; updated when there is significant change in mental status, behavior, or physical/medical condition; documented in the service recipient’s record and reviewed by the treatment team. The risk assessment must be completed by a licensed practitioner or mental health personnel with a minimum of a bachelor’s degree. (2) The assessment must identify any specific situations or issues including: chronological and developmental age; size; gender; physical, medical, and psychiatric condition; personal history, including any history of physical and/or sexual abuse; and cultural issues that may trigger behavior that might require the use of isolation, mechanical restraint, or physical holding restraint. (3) Assessment of Need: (a) Prior to the use of isolation, mechanical restraint or physical holding restraint, the service recipient must have an assessment that supports that the use of isolation or restraint is necessary to assure the physical safety of the service recipient or a person nearby and that all less restrictive interventions have been ineffective or determined to be inappropriate. (b) If the licensed practitioner authorizing the use of isolation, mechanical restraint or physical holding restraint is present at the time of the initiation of isolation or restraint, the licensed independent practitioner shall document the assessment of need in the service recipient’s record. (c) If the use of isolation, mechanical restraint or physical holding restraint is initiated in the absence of a licensed practitioner, an RN, LPN, or mental health personnel shall document the assessment of need in the service recipient’s record at the time use of isolation or restraint is initiated. The licensed independent practitioner authorizing the use of isolation or restraint must document the rationale for the use of isolation or USE OF ISOLATION, MECHANICAL AND PHYSICAL HOLDING RESTRAINT CHAPTER 0940-03-09 IN MENTAL HEALTH RESIDENTIAL TREATMENT FACILITIES restraint in the service recipient’s record at the time the verbal/telephone order is authenticated. (4) Follow-Up Assessment (a) Within one (1) hour of the initiation of the use of isolation, mechanical restraint, or physical holding restraint, a licensed practitioner or a registered nurse trained in accordance with 0940-03-09-.18 must see and assess the service recipient’s condition. This assessment must be conducted regardless of the length of time the service recipient is in isolation, mechanical restraint, or physical holding restraint. This assessment must be documented by the licensed independent practitioner or registered nurse in the service recipient’s record.