oversight

Mental Health: Extent of Risk From Improper Restraint or Seclusion Is Unknown

Published by the Government Accountability Office on 1999-10-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                            United States General Accounting Office

GAO                         Testimony
                            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-00-026
Mental Health: Extent of Risk From
Improper Restraint or Seclusion Is
Unknown
               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 citizens—people
               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).



               Page 1                                                                       GAO/T-HEHS-00-026
                       Mental Health: Extent of Risk From
                       Improper Restraint or Seclusion Is
                       Unknown




                       People with mental illness or mental retardation who receive residential
Background             treatment—and may be subject to restraint or seclusion—do 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 program, 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 present real risks of injury and death to individuals
Restraint and          in treatment and the staff who care for them. Restraint is the partial or
Seclusion Can Injure   total immobilization of a person through the use of drugs, mechanical
Patients and Staff     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



                       Page 2                                                      GAO/T-HEHS-00-026
    Mental Health: Extent of Risk From
    Improper Restraint or Seclusion Is
    Unknown




    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 holds—arms crossed in front of the body with the wrists held from
    behind—were 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.




    Page 3                                                      GAO/T-HEHS-00-026
                         Mental Health: Extent of Risk From
                         Improper Restraint or Seclusion Is
                         Unknown




                         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.



                         While restraint and seclusion can injure patients and staff, the full extent
Incomplete Reporting     of that risk is not known. HCFA requires treatment facilities that participate
Leaves the Full Extent   in Medicare and Medicaid to fulfill certain requirements but before August
of Patient Risk          of this year did not require hospitals—including psychiatric hospitals—to
                         report deaths that might be associated with restraint or seclusion. The lack
Unknown                  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   Neither the federal government nor the states comprehensively track the
Are Not Comprehensive    use of restraint or seclusion or injuries related to them across all types of
                         facilities that serve individuals with mental illness or mental retardation.

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



                         Page 4                                                                         GAO/T-HEHS-00-026
                          Mental Health: Extent of Risk From
                          Improper Restraint or Seclusion Is
                          Unknown




                          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 during—or can reasonably be assumed
                          to be related to—restraint 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. “Sentinel event” 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.


Deaths Reported to        Because reporting is so piecemeal, the exact number of deaths in which
Protection and Advocacy   restraint or seclusion was a factor is not known. We contacted the P&As for
Agencies Understate the   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
Problem
                          3
                           Federal Register, Vol. 64, No. 127, 36070 (July 2, 1999).



                          Page 5                                                        GAO/T-HEHS-00-026
Mental Health: Extent of Risk From
Improper Restraint or Seclusion Is
Unknown




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 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
process—a 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.



Page 6                                                       GAO/T-HEHS-00-026
                         Mental Health: Extent of Risk From
                         Improper Restraint or Seclusion Is
                         Unknown




                         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 covering restraint and seclusion vary among federal programs,
Policies Governing       states, and types of facilities. The federal government regulates the use of
Restraint and            restraint and seclusion in nursing homes and ICF-MRs but until recently
Seclusion Vary Among     had no such regulations for hospitals, including psychiatric hospitals. In
                         August 1999, HCFA incorporated patients’ rights provisions that address
Federal Programs,        restraint and seclusion into the hospital conditions of participation. These
States, and Facilities   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 facilities—even though they may be
                         state-licensed or may be receiving federal or state funding.

                         HFCA 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



                         Page 7                                                       GAO/T-HEHS-00-026
Mental Health: Extent of Risk From
Improper Restraint or Seclusion Is
Unknown




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).



Page 8                                                                         GAO/T-HEHS-00-026
                         Mental Health: Extent of Risk From
                         Improper Restraint or Seclusion Is
                         Unknown




                         Several states have successfully lowered the use of restraint and seclusion
Restraint and            in their public psychiatric health systems and put reporting requirements
Seclusion Can Be         into place. Restraint and seclusion rates in Pennsylvania’s state hospital
Reduced Through          system declined by more than 90 percent between 1993 and 1999. In
                         Delaware, the state’s ICF-MR introduced an initiative that reduced its
Regulation, Reporting,   restraint rate by 81 percent between 1994 and 1997. Typically, successful
Staffing, and Training   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.4 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

                         4
                          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).



                         Page 9                                                                       GAO/T-HEHS-00-026
Mental Health: Extent of Risk From
Improper Restraint or Seclusion Is
Unknown




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 restraints—the prone wrap-up, which immobilizes a person in a
face-down position, and a towel to prevent biting or spitting—were
associated with several injuries and deaths throughout the state.5 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

5
 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 “calming blanket” to provide the staff with a safe barrier.



Page 10                                                                          GAO/T-HEHS-00-026
Mental Health: Extent of Risk From
Improper Restraint or Seclusion Is
Unknown




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 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
“self-reinforcing” 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




Page 11                                                      GAO/T-HEHS-00-026
               Mental Health: Extent of Risk From
               Improper Restraint or Seclusion Is
               Unknown




               reducing the frequency of restraint-related staff injuries, which represent
               the costs of sick leave and overtime payments for staff to cover the shifts.


               The experience of several states shows that the use of restraint and
Concluding     seclusion can be reduced and that patients and staff are safer as a result.
Observations   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.


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




(201008)       Page 12                                                     GAO/T-HEHS-00-026
Ordering Information

The first copy of each GAO report and testimony is free.
Additional copies are $2 each. Orders should be sent to the
following address, accompanied by a check or money order
made out to the Superintendent of Documents, when
necessary. VISA and MasterCard credit cards are accepted, also.
Orders for 100 or more copies to be mailed to a single address
are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office
P.O. Box 37050
Washington, DC 20013

or visit:

Room 1100
700 4th St. NW (corner of 4th and G Sts. NW)
U.S. General Accounting Office
Washington, DC

Orders may also be placed by calling (202) 512-6000
or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and
testimony. To receive facsimile copies of the daily list or any
list from the past 30 days, please call (202) 512-6000 using a
touchtone phone. A recorded menu will provide information on
how to obtain these lists.

For information on how to access GAO reports on the INTERNET,
send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov




PRINTED ON    RECYCLED PAPER
United States                       Bulk Rate
General Accounting Office      Postage & Fees Paid
Washington, D.C. 20548-0001           GAO
                                 Permit No. G100
Official Business
Penalty for Private Use $300

Address Correction Requested