<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".09" citation="COMAR 10.21.12.09" title_num="10" subtitle_num="21" chapter_num="12" heading="Limitations on Restraint and Continuous Restraint.">
  <paragraph num="A.">
    <text>Staff may not initiate “standing” or “as needed” orders for restraint.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Each order for restraint, used for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, may only be renewed in accordance with the following limits not to exceed 24 hours total:</text>
    <paragraph num="(1)">
      <text>Four hours for adults 18 years of age or older;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Two hours for children and adolescents 9 to 17 years of age; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>One hour for children under 9 years of age.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>After 24 hours, before writing a new order for the use of restraint for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, a physician must:</text>
    <paragraph num="(1)">
      <text>See, assess, and conduct a face-to-face evaluation of the patient to determine whether continuous restraint is appropriate;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Document in the patient's medical record the observed behavior that confirms that the patient, if released from restraint, would continue to present a danger to self or others;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Follow all requirements outlined in this chapter, including but not limited to §B of this regulation; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Obtain the authorization of the clinical director or the clinical director's physician designee, neither of whom may be the treating physician.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Upon a request from a patient's treating physician, prior to authorizing continued restraint in accordance with §C(4) of this regulation, the clinical director or the clinical director's designee shall perform a face-to-face evaluation of the patient who is restrained.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Following the initial 24 hours of restraint authorized under §C of this regulation, additional periods of restraint, not to exceed 24 hours each, may be authorized only if the restraint is provided in accordance with §§B—D of this regulation.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Treatment Team Involvement.</text>
    <paragraph num="(1)">
      <text>Minimally, at regularly scheduled meetings, the patient's treatment team shall examine the use of restraint for that patient.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Within 5 working days from the initiation of continuous restraint, regardless of whether the patient remains in restraint, the treatment team shall:</text>
      <paragraph num="(a)">
        <text>When applicable, review the appropriateness of the continued use of restraint;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Establish and implement a plan to eliminate the need for further restraint; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Identify a team member who shall explain to the patient the potential risks and benefits of continuous restraint.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>