These regulations govern the use of quiet rooms and restraint in all facilities as defined in Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland. These regulations are supplemental to any other applicable law and regulation. In the event of conflict between these regulations and any other regulations or laws, the more stringent apply. In this chapter, the following terms have the meanings indicated. Terms Defined. Category I Restraint. “Category I restraint” means a device identified by the facility which limits a patient's mobility to the extent that the patient would not be able to independently reposition himself or herself or would otherwise be rendered helpless in an emergency. “Category I restraint” includes, but is not limited to, four-point restraints. “Category II restraint” means any device which is not considered by the facility as a category I restraint and includes, but is not limited to, mittens and vests. “Chief executive officer (CEO)” means the individual responsible for the overall management of a facility. “Child” means an individual younger than 12 years old. “Clinical director” means the psychiatrist in charge of the clinical care of all psychiatric patients in the facility. “Emergency situation” means a situation in which a patient's behavior poses a serious and imminent danger to the physical safety of self or others. “Facility” means any public or private hospital, clinic, or other institution that provides or purports to provide treatment or other services for a mental disorder, except an acute general hospital that does not have a separately identified inpatient psychiatric service. “Full view” means the unobstructed view by the assigned staff of a restrained patient. “Patient” means an individual receiving services for a mental disorder in a facility and includes any student receiving care and treatment in that facility. “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland. “Protective device” means any adaptive or assistive device or devices which restrict the movement of the whole or a portion of a patient's body for the purpose of preventing unintentional harm to self or others or which are used for promoting or maintaining normative body functions. Prone Restraint. “Prone restraint” means restricting the free movement of all or a portion of a patient’s body through the use of physical force or mechanical devices while the patient is in a prone position. “Prone restraint” does not mean a technique for transitioning a patient to a restraint position that involves momentarily placing the individual face down. “Quiet room” means an unlocked room that patients are not physically prevented from leaving, which is designated for patients' voluntary use to allow them time out of the company of other patients. “Registered nurse” means an individual who is licensed to practice registered nursing under Health Occupations Article, Title 8, Annotated Code of Maryland. Restraint. “Restraint” means: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely; or A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. “Restraint” does not include a helmet when used as a sole form of restraint or a protective device. “Seclusion” means the involuntary confinement of a patient under the direction of a physician or registered nurse alone in a room which a patient is physically prevented from leaving. “Trauma-informed care” means mental health treatment that includes: An appreciation for the high prevalence of trauma experienced by individuals receiving mental health services; An understanding of the neurological, biological, psychological, and social effects of trauma and violence, including sexual abuse and exploitation, on an individual; and An understanding of the environment, practices, and treatments that may need to be modified to address trauma issues. “Treatment team” means the patient's treatment team as defined in COMAR 10.21.03.02C. Staff authorized under the provisions of Regulation .05B of this chapter may use a restraint: Only during an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury; If ordered by a physician in writing; or If at the direction of a registered nurse, if a physician's order is obtained within 2 hours of the action. Staff may not use a restraint: As a mode or course of treatment; As punishment, coercion, discipline, or retaliation; For the convenience of staff; To prevent damage or destruction to property; or To prevent serious disruption of the therapeutic environment. Staff shall use a restraint: In a humane, safe, and effective manner; Without intent to harm or create undue discomfort to the patient; and and For the shortest possible length of time, regardless of the length of time in the physician's order. Staff authorized under the provisions of Regulation .05B of this chapter may order the use of a restraint only if the physician, following a clinical evaluation of the patient, determines that: The patient's behavior poses an emergency situation; and Less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. The approaches referred to in §D(2) of this regulation may include, but are not limited to: Clinical interventions; Quiet room; Medication or medications; Deescalation techniques; Trauma-informed care interventions; Calling the hospital's response team for assistance; and Consulting the patient's care plan for personalized strategies. When the definition of a restraint or a protective device is in dispute, in each case under discussion, the clinical director or the clinical director's physician designee shall clarify and document in the patient's medical record the device's correct purpose. The patient's treatment team shall document in the treatment plan the team's rationale for use of a protective device. A facility shall: Have a written policy specifying the method used to ensure that a patient whose primary language or method of communication is nonverbal is able to effectively communicate distress during a physical restraint or hold; and Ensure that all staff at the facility who are authorized to participate in a physical restraint or hold of a patient are trained in the method specified in the written policy in accordance with §A(1) of this regulation. A physician who is responsible either for the care of the patient or for assessment of the appropriateness of a restraint or, when the appropriate physician is not readily available to assess the patient, a registered nurse shall conduct a clinical evaluation of the patient to determine whether an emergency situation is present. Before using restraint, the physician or registered nurse shall assess whether less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. When a physician, as identified in §B of this regulation, is immediately available, the physician shall be responsible for determining a patient's need for a restraint and make the decision whether to restrain. Authorization in the Absence of a Physician. When a physician, as identified in §B of this regulation, is not immediately available, a registered nurse shall determine a patient's need for restraint and may initiate and direct the use of restraint. Within 2 hours of the implementation of the restraint, a physician shall give a written or verbal order for any restraint initiated by a registered nurse and, at that time, shall make the clinical determination to continue or to discontinue the restraint. When possible, staff shall advise a patient, in a nonthreatening manner, that continuation of a specific behavior may result in the use of restraint. When a physician or registered nurse determines that the use of a restraint is appropriate, staff involved shall make a reasonable effort to verbally persuade the patient to be cooperative with the restraint. Staff shall apply a restraint only in accordance with the facility's policy and procedure manual. For the patient's safety and the safety of others: Staff shall place the patient in the restraint in as dignified a manner as the situation permits, using the least amount of physical force necessary; As necessary, additional staff shall participate in the placement of a patient in restraint; The patient shall be free from subject prone restraint; and The patient shall be free from a restraint that: Applies pressure to the patient’s back; Obstructs the airway of the patient or impairs the patient’s ability to breathe; Obstructs a staff member’s view of the patient’s face; or Restricts the patent’s ability to communicate distress. Unless a physician or registered nurse determines that it is unsafe to do so, staff shall permit the patient to wear all or a portion of the patient's own clothes or another form of attire. Staff shall search the patient for potentially harmful objects. If staff determine a need for objects to be removed pursuant to §F of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. Unless contraindicated for safety reasons, staff shall permit the patient to wear eyeglasses, hearing aids, dentures, or prosthetic devices. When placing a patient in a restraint, staff shall inspect each restraining device and ensure that each restraining device is safely and securely applied. As necessary, staff shall ensure that each restraint is padded to provide appropriate protection for the patient. In addition to the requirements outlined in this chapter, when: Restraining a child, staff may not use four-point restraints; and Applying or repositioning a restraint, staff shall avoid the application of force on long bone joints. Regardless of the physical setting in which the patient is placed, at a minimum, one staff member shall be assigned continuously while the patient is in a category I restraint. While the patient is restrained, in order to provide appropriate clinical care, at a minimum, staff clinically trained to do so shall: Keep the patient in full view at all times; Protect the patient from harm by others; Closely observe the patient at least every 15 minutes, and document each observation by the observer; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, at least hourly, make and document personal contact with the patient for the purpose of: Determining if the patient has any special needs which need attention; Checking circulation of the extremities restrained; Adjusting the restraint; and Realigning the body or massaging the extremities restrained, or both; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, offer or provide the following: Full range of motion, every 2 hours; Toilet facilities, at least every 2 hours; Bathing and oral hygiene, at least once during a 24-hour period; Meals, at the regularly scheduled hours and under the supervision of nursing personnel; and Fluids, at least every 2 hours; and As clinically indicated, record temperature, pulse, blood pressure, and respirations. At least once every 2 hours, a physician or registered nurse shall assess the appropriateness of continuing the restraint and document the factors supporting the assessment in the patient's medical record. When the patient's behavior no longer places the patient or others in serious threat of violence or injury, the patient shall be released from restraint. Staff may not initiate “standing” or “as needed” orders for restraint. 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: Four hours for adults 18 years of age or older; Two hours for children and adolescents 9 to 17 years of age; or One hour for children under 9 years of age. 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: See, assess, and conduct a face-to-face evaluation of the patient to determine whether continuous restraint is appropriate; 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; Follow all requirements outlined in this chapter, including but not limited to §B of this regulation; and Obtain the authorization of the clinical director or the clinical director's physician designee, neither of whom may be the treating physician. 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. 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. Treatment Team Involvement. Minimally, at regularly scheduled meetings, the patient's treatment team shall examine the use of restraint for that patient. Within 5 working days from the initiation of continuous restraint, regardless of whether the patient remains in restraint, the treatment team shall: When applicable, review the appropriateness of the continued use of restraint; Establish and implement a plan to eliminate the need for further restraint; and Identify a team member who shall explain to the patient the potential risks and benefits of continuous restraint. Restraint Orders. A physician shall: To initiate the use of restraint: Enter an order in the patient's medical record; or Authorize an order to be written by a registered nurse on the physician's order sheet in the patient's medical record: Indicating that physician's verbal order for restraint; or Directing the release of the patient and the rationale for that release; Countersign all verbal orders within 24 hours of the order's being written; and Include in the order for restraint: The date and time that the order was written; The specific type of restraint to be used; The maximum duration of restraint from the time that the restraint was initiated; The specific rationale for restraint; Special precautions, if any, to safeguard the patient; The physician's signature; and In the case of a verbal order, the names of both the ordering physician and the registered nurse who received the verbal order. As soon as possible after implementation, but not later than the close of the shift, staff shall: Document the implementation of restraint in the patient's medical record; and Include in the documentation the following information: A description of the specific behavior leading to restraint; Whether and which less restrictive techniques were used, and, if not, why not; Whether a formal call for facility staff response was required, the names of staff assisting in the restraint, and the circumstances while restraining the patient; The readily observable physical condition of the patient; The date and time of the restraint and signature of the recorder; Whether the patient was permitted to wear the patient's own clothes or other attire and, if not, the reason or reasons for this; and A description of any physical injury to either the patient or others resulting from placement of the patient in restraint. While a patient is restrained, staff shall document the clinical interventions employed, including those listed in Regulation .08 of this chapter. Release from Restraint. When a physician clinically determines that a patient is to be released from restraint, the physician shall: Order the release and write, sign, and date a note indicating the rationale for the release; and If verbally ordering the release, write, sign, and date the note not later than 24 hours after a verbal order to release. When a registered nurse clinically determines that the release of the patient before the maximum period specified on a physician's order is appropriate, the registered nurse shall: Direct termination of the restraint; and Document, sign, and date the rationale for the termination of restraint in the patient's medical record. Patient Request. A patient may request the use of a quiet room and, unless clinically contraindicated, may be granted use of a quiet room. Unless staff terminates use of the quiet room for clinical reasons, the patient may terminate self-initiated use of the quiet room at any time. Staff Request. When staff, permitted by the facility to initiate and terminate use of a quiet room, determine that the use of the quiet room is clinically indicated, staff may request that a patient voluntarily enter into the quiet room. Staff may not coerce a patient into entering the quiet room. When the patient enters the quiet room, staff shall discuss with the patient: The recommended length of stay in the quiet room; The behaviors expected of the patient before and upon return to the milieu; and The primary interventions to be initiated if the use of the quiet room is terminated by the patient before the time recommended by staff or is determined to be ineffective. Staff shall determine the need for removal of any harmful objects in the room or from the patient. If staff determine a need for objects to be removed pursuant to §C of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. While a quiet room is in use, the staff shall assure that the quiet room door is not locked or in a position that prevents a patient from exiting the room voluntarily. Observation and Documentation. Staff shall: Be assigned to monitor the patient and the safety of the environment while a patient is in the quiet room; When the quiet room is used as a clinical intervention, observe the patient at least once every 30 minutes and document the observation in the patient's medical record; and At least every 2 hours, evaluate the effectiveness of the outcome and document the clinical rationale for continued use of the quiet room. A physician shall review the use of the quiet room after 6 hours and, if use of the quiet room is continued, at least every 24 hours after that. Use of a quiet room may be terminated at any time: Upon the decision of the patient; or As clinically determined by staff. The clinical director or the clinical director's designee shall review daily all uses of restraint and investigate unusual or possibly unwarranted patterns of use. The physician involved in the restraint may not function in the capacity outlined in §A of this regulation. A facility shall identify a committee to review periodically, but not less than quarterly, the use of restraint to assure that the standards maintained by the facility are, at a minimum, consistent with this chapter. Staff who implement orders for restraint: Shall have documented annual training in the proper use of physical restraint and hold including training for special populations which include, but are not limited to, children and the elderly; Shall have documented annual training in trauma-informed care and demonstrate competency in providing trauma-informed care services; and May not implement orders for restraint until trained by the facility to do so unless, in an emergency situation, the safety of the patient or others is threatened. The facility's chief executive officer or the chief executive officer's designee is responsible for assuring that the restraint devices used in that facility are maintained in accordance with acceptable standards for hygiene and safety. If seclusion is used in conjunction with restraint, staff shall also comply with COMAR 10.21.13. Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism. Excluding the prohibition described in §B of this regulation, staff may not vary from the standards identified in this chapter unless the variation is for an extreme crisis. There may not be any variance with standards established in this regulation and in Regulations .03 and .04, .06B—G and I—J, .07, .09A, .11, .12A and D—F, .13, and .14 of this chapter. Staff shall document, on the facility's variance report, a variance with standards permitted under this chapter. The CEO shall rule on and document each variance permitted in §A of this regulation to determine whether the variance was: An extreme crisis; A deviation from the facility's procedure; or A problem in the facility's policy which is correctable by administrative action. The CEO shall assure that the facility's quality assurance process incorporates a monthly review of any variance permitted in §A of this regulation. Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland Effective date: October 25, 1993 (20:21 Md. R. 1654) Regulation .01 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .02B amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .03 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .05 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .06D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .08D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .09 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation 10D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .12D, F amended effective February 14, 2026 (52:23 Md. R. 1139)