Mental Health: Extent of Risk From Improper Restraint or Seclusion Is
Unknown (Testimony, 10/26/1999, GAO/T-HEHS-00-26).

Pursuant to a congressional request, GAO discussed the effect of
improper restraint and seclusion on some of the country's most
vulnerable citizens--people with serious mental illness or mental
retardation.

GAO noted that: (1) as GAO recently reported, improper restraint and
seclusion can be dangerous to people receiving treatment for mental
illness or mental retardation and to staff in treatment facilities; (2)
while there is no comprehensive system to track injuries or deaths, GAO
found that at least 24 deaths that state protection and advocacy
agencies (P&A) investigated in fiscal year 1998 were associated with the
use of restraint or seclusion; (3) GAO believes there may have been more
deaths because only 15 states require any systematic reporting to P&As
to alert them to serious injuries and deaths; (4) GAO also found that
federal and state regulations that govern the reporting of injuries and
deaths and that govern the use of restraint and seclusions are not
consistent for different types of facilities; (5) the experience of
several states demonstrates that having regulatory protections and
reporting requirements can reduce the use of restraint and seclusion and
improve safety for individuals receiving treatment as well as for
facility staff; and (6) in GAO's September 1999 report, GAO made several
recommendations that, if adopted, should improve the safety of patients
and staff in a variety of treatment settings.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-00-26
     TITLE:  Mental Health: Extent of Risk From Improper Restraint or
	     Seclusion Is Unknown
      DATE:  10/26/1999
   SUBJECT:  Mental care facilities
	     Mental health care services
	     Mental illnesses
	     Mental hospitals
	     Persons with disabilities
	     State law
	     Reporting requirements
	     Safety standards
	     Safety regulation
IDENTIFIER:  Medicare Program
	     Medicaid Program

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Cover
================================================================ COVER

Before the Committee on Finance, U.S.  Senate

For Release on Delivery
Expected at 10:00 a.m.
Tuesday, October 26, 1999

MENTAL HEALTH - EXTENT OF RISK
FROM IMPROPER RESTRAINT OR
SECLUSION IS UNKNOWN

Statement of Leslie G.  Aronovitz, Associate Director
Health Financing and Public Health Issues
Health, Education, and Human Services Division

GAO/T-HEHS-00-26

GAO/HEHS-00-26T

(201008)

Abbreviations
=============================================================== ABBREV

  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  ICF-MR - intermediate care facilities for the mentally retarded
  JCAHO - Joint Commission for Accreditation of Healthcare
     Organizations
  P&A - protection and advocacy agency

MENTAL HEALTH:  EXTENT OF RISK
FROM IMPROPER RESTRAINT OR
SECLUSION IS UNKNOWN
============================================================ Chapter 0

Mr.  Chairman and Members of the Committee: 

We are pleased to be here today to discuss the effect of improper
restraint and seclusion on some of the country's most vulnerable
citizensï¿½people with serious mental illness or mental retardation. 
About 5.5 million adults experience severe mental illness each year,
about 240,000 of them requiring residential treatment in mental
hospitals, centers, or group homes.  In addition, an estimated
360,000 adults and children with mental retardation lived in
intermediate care facilities or smaller residential settings in 1998. 
Medicare, the federal program of health insurance for the elderly and
disabled, and Medicaid, the federal and state program of health
insurance for the poor, help pay for the treatment of eligible
individuals in these settings.  Because members of the Congress
became concerned about the safety of patients after a series of
articles in the Hartford Courant reported on restraint-related
deaths, we were asked to evaluate the risks involved in using
restraint and seclusion, the adequacy of current federal reporting
requirements and other protections, and what certain states had done
to address restraint and seclusion. 

In brief, as we recently reported, improper restraint and seclusion
can be dangerous to people receiving treatment for mental illness or
mental retardation and to staff in treatment facilities.\1 While
there is no comprehensive system to track injuries or deaths, we
found that at least 24 deaths that state protection and advocacy
agencies (P&A) investigated in fiscal year 1998 were associated with
the use of restraint or seclusion.  We believe there may have been
more deaths because only 15 states require any systematic reporting
to P&As to alert them to serious injuries and deaths.  We also found
that federal and state regulations that govern the reporting of
injuries and deaths and that govern the use of restraint and
seclusion are not consistent for different types of facilities.  The
experience of several states demonstrates that having regulatory
protections and reporting requirements can reduce the use of
restraint and seclusion and improve safety for individuals receiving
treatment as well as for facility staff.  In our September 1999
report, we made several recommendations that, if adopted, should
improve the safety of patients and staff in a variety of treatment
settings. 

--------------------
\1 Mental Health:  Improper Restraint or Seclusion Use Places
Patients at Risk (GAO/HEHS-99-176, Sept.  7, 1999). 

   BACKGROUND
---------------------------------------------------------- Chapter 0:1

People with mental illness or mental retardation who receive
residential treatmentï¿½and may be subject to restraint or seclusionï¿½do
so in a variety of settings.  Psychiatric patients may receive
inpatient treatment in traditional state hospitals, private
psychiatric hospitals, or community hospitals with psychiatric units. 
The trend toward less restrictive community-based settings has led to
more individuals with mental illness or mental retardation living in
smaller facilities and group homes. 

Federal funding through Medicare and Medicaid accounts for about 40
percent of the revenue for mental health treatment facilities. 
Medicare provides limited mental health coverage for individuals
older than 65 and some individuals younger than 65 who are disabled. 
In 1994, Medicare spent about $4.5 billion for mental health services
in private psychiatric hospitals and general hospitals.  The Medicaid
program covers certain low-income individuals for residential
services to treat mental disabilities.  Medicaid covers children and,
at state option, aged adults with mental illness, and it covers
adults and children with mental retardation.  Medicaid provides
inpatient mental health services for children younger than 21 in
general hospitals, psychiatric hospitals, and nonhospital settings. 
Individuals aged 65 and older may receive inpatient mental health
services in a hospital or nursing home.  Medicaid spending for
inpatient psychiatric treatment totaled more than $2 billion in
fiscal year 1996.  In the same year, Medicaid spent about $9.6
billion for intermediate care facilities for the mentally retarded
(ICF-MR), which provide long-term residential care and treatment.  In
addition, Medicaid covers care for children with mental illness and
adults and children with mental retardation through the home and
community-based waiver programs, which allow states to cover a
broader range of services in less restrictive settings such as group
homes.  State Medicaid programs spent $5.6 billion in federal and
state funding on home and community-based waiver services in fiscal
year 1996, some of which was used to provide residential treatment. 
The federal government through the Health Care Financing
Administration (HCFA) administers Medicare and HCFA and the states
administer Medicaid. 

   RESTRAINT AND SECLUSION CAN
   INJURE PATIENTS AND STAFF
---------------------------------------------------------- Chapter 0:2

Restraint and seclusion present real risks of injury and death to
individuals in treatment and the staff who care for them.  Restraint
is the partial or total immobilization of a person through the use of
drugs, mechanical devices such as leather cuffs, or physical holding
by another person.  Seclusion refers to a person's involuntary
confinement, usually solitary.  Restraint and seclusion can be
dangerous because restraining people can involve physical struggling,
pressure on the chest, or other interruptions in breathing.  Staff
can be injured while struggling to get residents into restraints or
seclusion. 

Clinicians, providers, and patient advocates generally agree that
when patients lose control to the extent that they or others are at
imminent risk of being physically harmed, staff can legitimately
restrain or seclude them in emergencies.  However, many patient
advocates, state mental health program officials, and representatives
of the psychiatric physician and nursing profession disagree as to
whether there is any other appropriate clinical use of restraint and
seclusion or whether they should be used only as a last resort. 

The dangers of restraint and seclusion have been recognized in the
mental health community.  The Joint Commission for Accreditation of
Healthcare Organizations (JCAHO), which accredits most hospitals
participating in Medicare and Medicaid, recently sent an advisory to
hospitals warning about the dangers of restraint and seclusion. 
JCAHO documented 20 deaths since 1996 caused by asphyxiation,
strangulation, cardiac arrest, and fire while people were in
restraint or seclusion.  These were similar to the causes of death
the Courant listed in its investigation, which included asphyxia,
blunt trauma, cardiac complications, drug overdoses or interactions,
strangulation or choking, and fire or smoke inhalation. 

Children are subjected to restraint and seclusion at higher rates
than adults and are at particular risk.  Several of the states that
took part in a study sponsored by the Department of Health and Human
Services (HHS) Center for Mental Health Services reported higher
restraint rates for children, including one state in which children
in state-run inpatient facilities were restrained four times more
frequently than adults.  Children are smaller and weaker than adults
are, so staff used to overpowering adults may apply too much pressure
or force when restraining children.  The following cases reported by
the National Alliance for the Mentally Ill illustrate the dangers of
restraining children: 

  -- In February 1999, a 16-year-old girl died in California of
     respiratory arrest with her face on the floor while being
     restrained by four staff members. 

  -- Basket holdsï¿½arms crossed in front of the body with the wrists
     held from behindï¿½were involved in the death of a 17-year-old
     girl in a Florida residential treatment center in November 1998
     and the death of a 9-year-old boy in North Carolina in March
     1999 after being restrained following a period of seclusion. 

The use of restraint and seclusion can also result in serious injury
and abuse.  During fiscal year 1998, P&As received about 1,000
complaints regarding restraint and seclusion and documented instances
of bruising and broken bones.  In one instance, a 24-year-old man
suffered a severe fracture in his right arm while facility staff were
struggling to restrain him and was subsequently placed in four-point
restraints and left for 12 hours with the broken arm, despite his
requests for medical attention.\2

Even if no physical injury is sustained, patients can be severely
traumatized while being restrained, especially those who had
previously been sexually abused.  A Massachusetts task force reported
that research indicates that at least half of all women treated in
psychiatric settings have a history of physical or sexual abuse.  The
task force found that the use of restraints on patients who have been
abused often results in their re-experiencing the trauma and
contributes to a set-back in the course of treatment. 

Restraint and seclusion can also lead to the injury of health care
workers.  The occupation of mental health care worker has been found
to be more dangerous than construction work.  Studies have documented
that the largest percentage of patient assaults on staff members
occurs during restraint or seclusion and that most staff injuries are
sustained while staff are trying to control patients who are being
violent. 

--------------------
\2 Four-point restraints immobilize a person on a bed with a cuff
around each wrist and ankle. 

   INCOMPLETE REPORTING LEAVES THE
   FULL EXTENT OF PATIENT RISK
   UNKNOWN
---------------------------------------------------------- Chapter 0:3

While restraint and seclusion can injure patients and staff, the full
extent of that risk is not known.  HCFA requires treatment facilities
that participate in Medicare and Medicaid to fulfill certain
requirements but before August of this year did not require
hospitalsï¿½including psychiatric hospitalsï¿½to report deaths that might
be associated with restraint or seclusion.  The lack of comprehensive
reporting makes it impossible to determine all deaths in which
restraint or seclusion was a factor.  However, through a survey of
each of the P&As for the 50 states and the District of Columbia, we
identified 24 deaths during fiscal year 1998 that were related to
restraint or seclusion. 

      REPORTING REQUIREMENTS ARE
      NOT COMPREHENSIVE
-------------------------------------------------------- Chapter 0:3.1

Neither the federal government nor the states comprehensively track
the use of restraint or seclusion or injuries related to them across
all types of facilities that serve individuals with mental illness or
mental retardation.  Federal requirements on reporting injuries and
deaths and restraint or seclusion differ by type of facility. 
Starting in August of this year, hospitals are now required, as a
condition of participating in Medicare or Medicaid, to report to HCFA
deaths that occur duringï¿½or can reasonably be assumed to be related
toï¿½restraint or seclusion.\3 Other facilities that provide
residential services to mentally ill or mentally retarded individuals
and that are paid by Medicare or Medicaid are not required to report
such deaths to HCFA.  Federal regulations require ICF-MRs and nursing
homes to provide, during their regular oversight surveys, information
that can be used for tracking the use of restraint and seclusion. 
However, there are no federal reporting requirements on the use of
restraint and seclusion for any other type of facility, such as
community-based group homes funded under the Medicaid waiver program
or residential treatment centers for children. 

Most states do not comprehensively track data on either the use of
restraint or related injuries.  Further, JCAHO recently surveyed
states regarding their requirements to report sentinel events. 
ï¿½Sentinel eventï¿½ is defined as an unexpected occurrence involving
death or serious physical or psychological injury or the risk of such
death or injury.  While the results are preliminary, only half the
states that had responded by March 1999 indicated that they had a law
that required reporting sentinel events to a state agency.  In our
survey of P&As, we found that only 11 states track restraint use in
private psychiatric facilities. 

JCAHO does not require hospitals to report sentinel events but
encourages voluntary reporting.  JCAHO reports that since it adopted
its current policy on voluntary reporting of sentinel events in 1996,
it has received reports of 24 restraint-related deaths in facilities
it accredits.  It published a Sentinel Event Alert based on these
reports in November 1998 with a summary of the analyses of 20
restraint-related deaths from the sentinel event database.  However,
voluntary reporting to JCAHO is not complete.  JCAHO found out about
at least three deaths that had not been reported to it as a result of
the Hartford Courant's report of deaths.  Even if a sentinel event is
not reported to it, JCAHO expects hospitals to conduct an internal
review to determine how to avoid similar incidents. 

--------------------
\3 Federal Register, Vol.  64, No.  127, 36070 (July 2, 1999). 

      DEATHS REPORTED TO
      PROTECTION AND ADVOCACY
      AGENCIES UNDERSTATE THE
      PROBLEM
-------------------------------------------------------- Chapter 0:3.2

Because reporting is so piecemeal, the exact number of deaths in
which restraint or seclusion was a factor is not known.  We contacted
the P&As for each state and the District of Columbia and asked them
to identify people in treatment settings who died in fiscal year 1998
and for whom restraint or seclusion was a factor in their death.  The
P&As identified 24, but this number is likely to be an
understatement, because many states do not require all or some of
their facilities to report such incidents to a P&A. 

The Congress has required the states to establish or designate P&As
to protect people with mental illness or mental retardation from
abuse and neglect by providers when state oversight is insufficient. 
This system began for individuals with mental retardation in 1975,
following the discovery of severe patient neglect and abuse at a
state-run facility for the mentally retarded in New York, and it was
expanded to individuals with mental illness when the Congress learned
of similarly appalling conditions in psychiatric hospitals in 1985. 
P&As are charged with investigating reports of abuse, neglect, and
other violations of the rights of mentally disabled individuals in
institutional care and with pursuing legal and administrative
remedies.  In most states, the same P&A agency serves both
individuals with mental illness and those with mental retardation. 

Despite their charge, P&A representatives told us that they do not
learn of all the deaths that may be related to restraint or
seclusion.  Only 15 of the 51 P&As receive any kind of systematic
reports of deaths from their states or psychiatric facilities.  Of
the 15, 9 receive death reports for state facilities only and not for
private facilities. 

Because of the lack of reporting requirements in so many states, most
P&As learn about deaths through complaints from family, patients, and
staff as well as from on-site monitoring.  Even with these ad hoc
methods, only 22 of these agencies had deaths reported to them in
1998 by any means.  Of the deaths reported to the P&As in fiscal year
1998, just 5 states accounted for more than two-thirds, and no deaths
were reported to the P&As in 28 states. 

P&As investigated only about 30 percent of the deaths they learned
about.  One agency in New York accounted for almost one-third of all
the death investigations, while four other agencies investigated 107
deaths combined.  P&A officials also told us that their ability to
conduct investigations is hindered by limited resources and obstacles
in obtaining records, particularly the incident reports and medical
records that enable them to thoroughly investigate deaths.  According
to some P&A officials, health facilities often claim that these
records are part of the peer review processï¿½a process in which
medical professionals in a facility review incidents.  While P&As may
have legal rights to review the records, a P&A may have to litigate
to obtain them.  This can use up its limited resources and delay
needed investigations. 

Information may be even more difficult to obtain from private
facilities.  Obtaining information from private facilities is
becoming increasingly important as more individuals with mental
illness are being served in them.  While many state agencies may
gather data from their own facilities, private psychiatric facilities
are usually not required to report data to either the state or the
P&As. 

   POLICIES GOVERNING RESTRAINT
   AND SECLUSION VARY AMONG
   FEDERAL PROGRAMS, STATES, AND
   FACILITIES
---------------------------------------------------------- Chapter 0:4

Policies covering restraint and seclusion vary among federal
programs, states, and types of facilities.  The federal government
regulates the use of restraint and seclusion in nursing homes and
ICF-MRs but until recently had no such regulations for hospitals,
including psychiatric hospitals.  In August 1999, HCFA incorporated
patients' rights provisions that address restraint and seclusion into
the hospital conditions of participation.  These requirements
establish the right to freedom from restraint or seclusion for
purposes of coercion, discipline, or staff convenience.  Restraint
and seclusion can be used only for medical and surgical care and in
emergencies to ensure a patient's physical safety and only after less
restrictive interventions have been found ineffective to protect a
patient or others from harm.  However, current regulations do not
protect patients receiving psychiatric care in nonhospital settings
such as residential treatment centers for children and group homes. 

The states have varying degrees of regulation and oversight for
restraint and seclusion.  Some states have different standards for
their state-run facilities and private providers.  In addition,
private psychiatric hospitals are frequently not subject to the same
degree of oversight as the state-run facilities.  Some states like
New York and Pennsylvania that have extensive regulation of their
public hospitals have not imposed the same requirements on privately
operated facilitiesï¿½even though they may be state-licensed or may be
receiving federal or state funding. 

HCFA relies primarily on the accreditation process to determine
whether privately operated facilities such as hospitals are eligible
to participate in Medicare and Medicaid.  We found that
representatives of health care providers and family advocates
differed on whether the accreditation process alone is sufficient to
protect patients from improper restraint and seclusion.  JCAHO, which
accredits about 80 percent of the hospitals that participate in
Medicare, applies the same standards on restraint and seclusion in
hospitals as it applies in nonhospital behavioral health care
treatment facilities.  In JCAHO's accreditation survey, the surveyors
review records to determine whether restraint or seclusion is being
used and documented according to facility policy.  It does not set
standards regarding training and clinical issues such as the
frequency of monitoring and the types of restraint that are
preferable. 

Representatives of health care providers told us that they believe
that the accreditation process is the most appropriate way to ensure
that patients are protected from improper restraint and seclusion. 
They said that a voluntary review process allows the facility to
address any systemic clinical problems and develop plans for
improving quality.  In contrast, many advocates are concerned that
the accreditation process is not sufficient to establish consistent
patient protection because it stresses compliance with each
facility's own policies.  JCAHO surveyors tour facilities and talk
with patients and staff to better understand their care issues. 
However, advocates have noted that the process emphasizes paperwork
reviews that can miss ongoing problems with the quality of care.  The
HHS Inspector General recently reported that the accreditation
process plays a positive role in the improvement of quality but
cannot be relied upon alone to ensure patient protection.\4

Some of the advocates and state administrators we interviewed believe
that the most effective monitoring system involves a combination of
internal and external oversight.  External monitors complement
internal quality control systems by providing an independent
perspective.  In some cases, courts have appointed independent
monitors to ensure compliance with specific requirements and the
safeguarding of basic patient rights in facilities that have had
serious problems.  In addition to using accreditation or state
licensing surveyors and P&As, some states allow trained lay monitors
to visit mental health facilities unannounced and assess
environmental conditions.  In Delaware, for example, if a monitor
reports a concern about conditions in the state psychiatric hospital,
the facility must respond within 10 days.  Because staff at the
facilities know that management reviews the reports and acts on them,
they sometimes inform monitors about concerns that affect patient
care, such as low staffing levels. 

--------------------
\4 HHS, Office of Inspector General, The External Review of Hospital
Quality:  A Call for Greater Accountability (Washington, D.C.:  July
20, 1999). 

   RESTRAINT AND SECLUSION CAN BE
   REDUCED THROUGH REGULATION,
   REPORTING, STAFFING, AND
   TRAINING
---------------------------------------------------------- Chapter 0:5

Several states have successfully lowered the use of restraint and
seclusion in their public psychiatric health systems and put
reporting requirements into place.  Restraint and seclusion rates in
Pennsylvania's state hospital system declined by more than 90 percent
between 1993 and 1999.  In Delaware, the state's ICF-MR introduced an
initiative that reduced its restraint rate by 81 percent between 1994
and 1997.  Typically, successful strategies to reduce restraint and
seclusion rates have similar components:  a defined set of principles
and policies to clearly outline when these measures can be used,
strong management commitment, the reporting of restraint and
seclusion use, oversight and monitoring, and intensive staff training
in behavioral assessment, nonviolent intervention, and using safe
restraint techniques as a last resort. 

Delaware, Massachusetts, New York, and Pennsylvania have adopted
strategies to reduce restraint use in their public mental health or
mental retardation service systems.  The officials we met with at the
state health departments indicated that the primary element for their
success in reducing restraint use is management commitment. 
Management philosophy, not the severity of patients' mental
disability, was the most important factor in determining restraint
use among different state hospitals, according to a 1994 study
conducted by the New York Commission on Quality of Care.\5 Management
can take responsibility for shaping the overall culture in which
restraint and seclusion are considered either routine practice or
last-resort measures.  An integral part of this commitment is a
clearly delineated set of policies and procedures governing the use
of restraint and seclusion for staff to follow. 

For example, Pennsylvania, which administers a system of 10
facilities with more than 3,000 residential psychiatric patients, was
able to reduce both restraint and seclusion hours by more than 90
percent between 1993 and 1999.  The state mental health leadership
accomplished this by first emphasizing to all hospital administrators
and staff that restraint and seclusion are not treatment but, rather,
represent an emergency response to a treatment failure that resulted
in a patient's loss of control.  The Department of Mental Health
issued policies that specified that restraint or seclusion can be
used only after all other interventions have failed and only when
there is imminent danger of the patient or others coming to physical
harm.  A physician's on-site assessment is required within 30
minutes.  According to state officials, there was some initial
opposition to these policies within the facilities, but the
department's emphasis on maintaining adequate staffing and improving
crisis management training allowed it to gain the support of
psychiatrists and direct care workers. 

Reporting requirements are central to lowering restraint use and
improving patient safety.  Officials in New York and Pennsylvania
stated that accurate and complete reporting allows hospital
administrators to compare their facilities with others.  This creates
an incentive for administrators with high restraint rates to find
ways to reduce them so that they are more in line with those of their
peers.  A 1999 survey by the National Association of State Mental
Health Program Directors indicates that 18 states currently collect
data on restraint or seclusion in their public hospitals. 

In addition to tracking restraint rates, the reporting of deaths and
sentinel events to an independent agency can help improve patient
safety.  New York is unique among the states in its longstanding,
comprehensive reporting requirement.  All licensed hospitals that
provide inpatient psychiatric care must report all deaths to the
Commission on Quality of Care as well as to the relevant state agency
and must indicate whether a patient was secluded or restrained within
the 24 hours before his or her death.  Mandatory reporting and
investigation allow an independent entity to analyze events at
multiple facilities.  Because the commission and other agencies
review information from the entire state, they can determine whether
incidents that appear to be isolated events from the perspective of
individual providers are actually part of a pattern.  For example,
comprehensive incident reviews led to the discovery that the use of
two authorized restraintsï¿½the prone wrap-up, which immobilizes a
person in a face-down position, and a towel to prevent biting or
spittingï¿½were associated with several injuries and deaths throughout
the state.\6 As a result of these analyses, these two types of
restraint were banned. 

Clinicians, advocates, labor unions representing direct-care mental
health workers, program administrators, and providers consistently
stress that training and adequate staff-to-patient ratios are
essential to safely minimize the use of restraint and seclusion. 
Nurses and direct-care staff need to have effective alternative
methods for handling potentially violent patients if they are to
reduce their use of restraint and seclusion.  In the states we
visited, training programs that address how to handle potentially
violent or aggressive patients were an integral part of the effort to
safely reduce reliance on restraint and seclusion.  In HCFA's interim
final rule implementing new general and psychiatric hospital
conditions of participation in Medicare and Medicaid, the agency has
added requirements that hospitals train their staff in alternative
techniques to lessen the use of restraint and seclusion, but these
requirements do not extend to other facility types. 

Delaware, Massachusetts, New York, and Pennsylvania have initiated
training programs that emphasize crisis prevention.  The goal of
training is to provide staff with the skills to assess potentially
violent situations and intervene early to help patients regain
control.  State officials as well as labor union representatives
stressed that direct-care staff must be trained in alternative
techniques if a facility is serious about reducing restraint and
seclusion. 

Delaware ICF-MR officials told us that patient and staff injuries
decreased after staff had been trained in alternative ways of
managing patient behavior.  According to a patient advocate,
Delaware's emphasis on reducing restraint rates was precipitated by a
1994 restraint-related death in the state ICF-MR.  Following the
implementation of a new training program that emphasized
patient-centered training in crisis prevention and new management
priorities, this facility reduced the number of emergency restrictive
procedures by 81 percent between 1994 and 1997, with the number of
procedures per resident falling from 1.38 to 0.29 during that time. 
Along with this reduction in restraint, the number of major injuries
to residents fell by 78 percent and resident behavior improved.  A
psychologist from Delaware's ICF-MR noted that once staff have
experienced success in calming a patient through alternative means
when they would have otherwise used restraint, the new techniques
become ï¿½self-reinforcingï¿½ because staff prefer to use the less
drastic measures. 

The mental health program officials we met with indicated that
training in alternatives to restraint and seclusion and maintaining
adequate staff levels are costly but that they can save money in the
long run by creating a safer treatment and work environment.  Data
from state hospitals in New York indicated that usually facilities
with higher restraint and seclusion rates had higher rates of staff
injury and lost staff time.  A New York official noted that many of
the injuries classified as assaults actually take place during
restraint and seclusion procedures.  According to state officials,
staff training has been found to save the state money by directly
reducing the frequency of restraint-related staff injuries, which
represent the costs of sick leave and overtime payments for staff to
cover the shifts. 

--------------------
\5 New York State Commission on Quality of Care for the Mentally
Disabled, Restraint and Seclusion Practices in New York State
Psychiatric Facilities (Albany, N.Y.:  1994). 

\6 Certain hospitals have authorized the use of a towel as a
precaution against biting and spitting during take-down and the use
of restraints to protect staff against possible infection.  The
commission indicated that no objects should ever be placed over or
near a patient's face because of the danger of asphyxiation, and it
recommended that staff wear gloves and masks and, if necessary, wrap
the patient in a ï¿½calming blanketï¿½ to provide the staff with a safe
barrier. 

   CONCLUDING OBSERVATIONS
---------------------------------------------------------- Chapter 0:6

The experience of several states shows that the use of restraint and
seclusion can be reduced and that patients and staff are safer as a
result.  Successful strategies include ensuring management
commitment, providing clear guidelines and a comprehensive reporting
requirement, maintaining adequate staffing levels, and providing
training. 

The federal government has a major role in funding services for
people with mental illness and mental retardation.  HCFA has taken
positive steps to ensure better reporting and patient protection
through its new hospital conditions of participation.  However, we
believe that more can be done to ensure that Medicare and Medicaid
patients with mental illness or mental retardation are protected from
improper seclusion and restraint and from injuries and deaths.  In
our recently released report, we recommended that HCFA should develop
consistent policies to ensure that mentally ill or mentally retarded
individuals are given protection against inappropriate restraint and
seclusion in every treatment setting that Medicare and Medicaid fund. 
We recommended that the use of restraint and seclusion and any
associated injuries or deaths be reported to the state licensing body
and state P&A.  In addition, we recommended that facility staff
regularly receive training in safe methods to handle agitated
individuals, including training in alternatives to using restraint
and seclusion.  HCFA officials said that they would review and
consider implementing each of our recommendations in the near future. 

-------------------------------------------------------- Chapter 0:6.1

Mr.  Chairman, this concludes my statement.  I will be happy to
answer your questions. 

*** End of document. ***