Hospital Conditions of Participation for Patients' Rights
Seclusion and Restraint for Behavior Management § 482.13(f)(3)(ii)(C) Tag A 786

A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of this intervention.

Statement of Problem/Concern
The one-hour rule compromises operations and safe patient care by forcing the Medical Staff or "licensed independent practitioners" to physically come to the hospital to evaluate patients placed in behavioral restraints. This requirement places an arbitrary and unnecessary burden on hospitals to comply. Should hospital regulations or state law preclude the use of "licensed independent practitioners", the burden for evaluation falls entirely upon the Medical Staff. If the Medical Staff objects, because of the inconvenience involved or simply the recognition that being a physician does not automatically convey special insight into patient behavior, the hospital is faced with either not restraining the patient in order to comply with the standard (thereby placing the patient, other patients, and staff at risk), or acting in the patient's best interests by restraining them and then hope the hospital is not subjected to civil monetary penalties or other discipline by the Center for Medicare and Medicaid Services (CMS) if an investigation ensues.

In a comment letter addressed to Ms. Joan Simmons, Deputy Director, Health Care Financing Administration (now CMS), on January 11, 2000, ASHRM stated that the one-hour rule may be an impossible standard for some hospitals to meet (e.g., rural hospitals).

ASHRM Recommendation:
Set aside the "in person" requirement altogether and allow for a telephone consultation or, as is the case in other situations, permit the nursing staff to simply implement and/or suspend some emergency interventions with subsequent sign-off by the patients' treating physician or hospital.

In ASHRM's comment letter of January 11, 2000, ASHRM recommended that, while a telephone call may be inadequate, the interpretive guidelines do not speak to the use of two-way audiovisual observations, real-time telemetry transmission of vital signs, and two-way communication with personnel attending the patient. Such a model provides considerable observation and interaction to enable the physician or licensed independent practitioner to evaluate the patient. Thus, it is recommended that this option be included as an alternative to an on-site face-to-face evaluation.

How Solution maintains original intent
The proposed solutions facilitate prompt assessment of the incident/situation that led to the intervention, as well as the physiological and psychological condition of the patient at the time of the assessment.