Mental Health

Only 15 states systematically alert protection and advocacy agencies about mentally ill or retarded people who have died as a result of improper restraint or seclusion in residential treatment settings. Most agencies receive reports only from state facilities, so that even these reporting systems are not comprehensive. Reports of deaths cannot always be thoroughly investigated because the agencies have had difficulty gaining access to medical records. From partial information from 51 such agencies, GAO identified 24 deaths associated with restraint or seclusion in fiscal year 1998. Fragmentary reporting suggests the actual number may be higher. No federal regulations govern the use of restraint or seclusion in psychiatric hospitals, residential treatment centers for children, or community group homes. Most state regulations do not apply to privately run facilities. Some states have found that reducing the use of restraint and seclusion improves safety for patients and staff alike. The Health Care Financing Administration (HCFA) should extend to people in any treatment setting funded by Medicare and Medicaid the same policies on restraint and seclusion that now protect individuals in long-term care settings and hospitals. HCFA should also improve reporting and require staff training in applying restraint and seclusion and in alternative ways to deal with potentially violent situations. GAO summarized this report in testimony before Congress; see: Mental Health: Extent of Risk From Improper Restraint or Seclusion Is Unknown, by Leslie G. Aronovitz, Associate Director for Health Financing and Public Health Issues, before the Senate Committee on Finance. GAO/T-HEHS-00-26, Oct. 20 (eight pages).

GAO noted that: (1) improper restraint and seclusion can be dangerous to both people receiving treatment and staff, but the full extent of related injuries and deaths is unknown; (2) there is no comprehensive reporting system to track such injuries and deaths or the rates of restraint and seclusion use by facility; (3) GAO's telephone survey of 51 state Protection and Advocacy agencies (P&A) found that only 15 states have any systematic reporting to alert these agencies to any deaths that occur among individuals in residential treatment settings; (4) even these reporting systems are not comprehensive, because most agencies that receive reports get them only from state facilities; (5) on the basis of the partial information available from these 51 agencies, GAO identified 24 deaths associated with restraint or seclusion during fiscal year 1998; (6) because reporting is so fragmentary, GAO believes many more deaths related to restraint or seclusion may occur; (7) data on use of restraint and seclusion are also fragmentary because most facilities are not required to report these data to oversight agencies; (8) federal and state regulations governing restraint and seclusion for individuals with mental illness and mental retardation are inconsistent across types of facilities; (9) the federal government regulates the use of restraint and seclusion in nursing homes and state Intermediate Care Facilities for the Mentally Retarded, but until recently, no federal regulations governed their use in other facilities, such as psychiatric hospitals, residential treatment centers for children, or community group homes; (10) in July 1999, the Health Care Financing Administration (HCFA) issued an interim final rule with revised Medicare conditions of participation for hospitals that address restraint and seclusion use; (11) although this is a positive first step, people in residential treatment centers and group homes participating in the Medicaid Home and Community-Based Waiver program have limited federal protection; (12) while some states have regulations in place governing the use of restraint and seclusion, often these regulations do not apply to privately operated facilities; and (13) on the basis of the experience of several states, having regulatory protections and reporting requirements can reduce the use of restraint and seclusion and improve safety for patients and staff.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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