Implement physical monitoring and observation of a patient who is restrained.
The RN/LPN (licensed practical nurse) ensures monitoring and observation at a minimum, as follows:
Document restraint monitoring information in the patient's record (e.g. Restraint Monitoring Checklist).
If patient’s physical safety is a factor, increase the frequency of observation or provide 1:1 constant observation. Constant observation by an RN/LPN for 3-4 Point Restraints (e.g. bilateral wrist and ankle restraints) may not be delegated to Unlicensed Health Care Providers (UHCP).
If less-restrictive restraints are unsuccessful, progress from least to most restraining, based on patient and assessment (e.g. patient’s physical and mental condition).
Every two hours:
Assess intervention effectiveness or ineffectiveness, including if behaviour is unchanged, escalating, or de-escalating, or if the patient has settled or is sleeping.
When the patient is no longer a risk to themselves or others, and is able to tolerate discontinuation or reduction to a less restrictive restraint (e.g. from pelvic holder to Access Controlled Egress Door):
Continue regularly 5P Purposeful Rounding with patient.
Debrief with Health Care Team, patient, Circle of Support/SDM to begin to re-establish the therapeutic relationship. Review what did and did not work, as well as any complications or safety concerns. Debriefing with patients/families/SDMs and staff has also shown to be helpful in preventing future restraint episodes. Update the care plan accordingly.