NURSING PATIENT CARE POLICY & PROCEDURE
April 4, 2017
Nursing Manual (Red)
Policy #: 14.34A
Title: Inpatient Psychiatry Seclusion Suite
A. To define use and limitations of the Seclusion Suite as a separate locked suite on
the Inpatient Psychiatric Unit.
B. To identify expectations of care for patients in this area when the door is locked.
Psychiatric patients, who demonstrate by their words or actions, that they are in need
of closer observation and/or present a danger to self and/or others, should be placed in
the Seclusion Suite when possible. The door to the Seclusion Suite will be open
unless there is a clinical indication to close and lock the doors. These indications
include but are not limited to patients who have demonstrated serious sexual risk to
others, patients who, because of their verbal acting-out and noise level, create an
unfriendly unit environment, patients who are wandering into other patient’s rooms,
patients on elopement precautions and patients who demonstrate a level of disruption
that is determined can be managed in the confined space but not to the level of
seclusion. When the door to the Seclusion Suite is locked for one of these reasons,
staff will assess if it is appropriate to have more than one patient in the Seclusion
A. The Nurse Care Team Leader, in conjunction with the primary nurse/team nurse,
determine whether a patient can benefit from staying in the Seclusion Suite. A
provider’s order is not required to use the Seclusion Suite.
B. The primary/team nurse notifies attending physician or resident on-call that the
decision was made and provide the rationale. RN will document rationale in the
patient’s clinical record
C. Staff may remove items from the suite, such as hand sanitizer, hand soap or
furniture, if it is deemed necessary for patient safety.
D. At a minimum, the patient will be visually checked every ten (10) minutes by a
NA or RN... Ten-minute checks will be documented on the Daily Care doc
flowsheet in the clinical record.
E. The door to the seclusion suite will be opened as soon as the risk has been
F. If the seclusion suite door is locked in the event of a fire or drill, the door will
remain locked and staff will remain with the patient until the “all clear” is called
or evacuation is required according to UW Health Clinical Policy 5.1.4,
Page 2 of 2
Evacuation of Staff & Patients from Locked Psychiatric Inpatient Unit. Staff will
remain with patient in the event of a tornado alert or drill.
IV. UWHC CROSS REFERENCE
UW Health Clinical Policy 5.4.1, Evacuation of Staff & Patients from Locked
Psychiatric Inpatient Unit
V. REVIEWED BY
Nurse Manager, Psychiatry
Nursing Patient Care Policy and Procedure Committee, March 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nursing Executive