.22 Reports and Action Required in Unusual Circumstances.

A. Serious Emotional Disturbances. A facility may not accept or keep patients who destroy property or are dangerous to themselves or others, or who have acute symptoms of mental illness.

B. Action to Be Taken if a Patient Becomes Actively Disturbed. The following action shall be taken:

(1) If a patient becomes actively disturbed, the personal physician shall be notified immediately.

(2) A restraint may be used only if all of the following conditions are met:

(a) Failure to use a restraint or restraints is likely to endanger the health or safety of the patient or others;

(b) There is a written physician's order for the use of the restraint or restraints, which shall comply with the following requirements:

(i) The physician's written order for the restraint or restraints shall be for a specified maximum period of time, not to exceed 24 hours.

(ii) The necessity for the use of the restraint or restraints shall be documented, and

(iii) The frequency of patient observations by licensed personnel on not less than an hourly basis during the period of time that the restraint or restraints or the effects of the restraint or restraints are present shall be indicated;

(c) Appropriate documentation by licensed personnel shall be recorded in the clinical record;

(d) The facility may not re-impose a restraint or restraints except upon the written order of a physician who has personally observed the patient since the previous restraint or restraints order was imposed.

(3) A restraint or restraints may not be ordered PRN.

(4) If a physician is not immediately available, a registered nurse may authorize the use of a physical restraint or restraints for a period not to exceed 4 hours in any 30-day period. Licensed personnel shall observe the patient hourly. The patient shall be seen by a physician if the restraint or restraints are to be applied for more than the initial 4-hour period.

C. Locked Doors Prohibited. Patients may not be kept behind locked doors, that is, doors which patients cannot open. If the patient becomes too difficult to manage, the patient shall be transferred to a suitable facility selected by the attending physician. If the physician so orders, patients who have a tendency to wander may be confined to their rooms by screen doors or folding gates.

Agency Note: Supervision should be adequate to prevent patients from intruding into the rooms of other patients.

D. Unusual Occurrences. Any occurrence such as the occurrence of suspected mental disturbance, communicable disease, or symptomatic condition of importance to public health, poisoning, or other serious occurrence which threatens the welfare, safety, or health of any patient shall be reported immediately to the local health department. The administrator of the facility shall be responsible for seeing that appropriate procedures and reporting are carried out. An occurrence of a communicable or suspected communicable disease shall be reported and acted upon in accordance with medical asepsis as described in COMAR 10.06.01 Communicable Diseases and COMAR 10.15.03 Food Service Facilities.

Agency Note: Utilization Review. A utilization review plan should be developed with the advice of the professional personnel responsible for the establishment and enforcement of patient care policies. It is suggested that there be established a multi-discipline audit team to participate in an ongoing system of internal patient care audit.