b'Reducing ligature risk by having the minimum necessaryparameters established in the treatment plan would be in patient rooms can improve patient safety, specificallypermitted. Since the use of restraints to prevent self-injury in nourishment rooms, visitor storage, light fixtures, andis needed for these types of rare, severe, medical and exam rooms within the hospital setting. Staff shouldpsychiatric conditions, the specific requirements below for secure personal belongings and remove any other items. the management of violent or self-destructive behavior do not apply:Repetitive Self-Mutilating Behavior Face to face If a patient is diagnosed with a chronic medical or psychiatric condition and the patient engages in theTime limited ordersrepetitive self-mutilating behavior, a standing or PRN orderEvaluation every 24 hours before renewal of the orderfor restraint to be applied in accordance with specific Standard Requirements Non-violent (Medical) Violent (Behavioral) SeclusionPatient Safety Plan (upon admission) N/A X XInitiation of R/S Emergency application,Emergency application,Emergency application, as necessary as necessary as necessaryOrder for R/S During During or immediatelyDuring or immediately (within a few minutes) (within a few minutes)or immediately (within 30 minutes) During Within 24 hours Within 24 hoursor immediately (within 30 minutes) During X Xor immediately (within 30 minutes) X X XOrder signed by QLP (if verbal orWithin 24 hours Within 24 hours Within 24 hourstelephone)Notification of Nursing Leadership [Operations Administrator (OA)/ X X XDirector]Initial Nursing Documentation X X X 12 years of age and under: Direct observation (face-Continuous Nursing Monitoring andto face or seclusion Documentation Every 2 hours Every 15 minutes window) for first hour and at least every 15 minutes thereafter. Over 12 years of age: Every 15 minutesRN Evaluation Every 2 hours Every 60 minutes Every 60 minutesPlan of Care X X XAs soon as possible, butAs soon as possible, but Debriefing Within 24 hours no longer than with 24no longer than with 24 hours of R/S releasehours of release from from R/SNCH Policy Description: Restraint and Seclusion v62024 Survey Readiness Guide 41'