Ala. Admin. Code r. 580-2-9-.23 - Child and Adolescent Seclusion and Restraint

Because of the high-risk nature of seclusion and restraint procedures and the potential for harm to consumers, the DMH MI Division Policy on Restraint and Seclusion is included here to place the standards within the proper context.

(1) Children/adolescents residing or receiving treatment in a community-based setting certified by the Alabama Department of Mental Health have the right to be free of restraint and seclusion. Restraint and seclusion are safety procedures of last resort. Restraint and seclusion are not therapeutic interventions and are not interventions implemented for the purpose of behavior management.

(2) Children/adolescents may be placed in seclusion or physically restrained only in emergency situations when necessary to:

(a) Prevent the child/adolescent from physically harming self or others.

(b) Less restrictive alternative treatment interventions have been unsuccessful or are determined not to be feasible.

(c) When authorized by a qualified individual.

(3) The Alabama Department of Mental Health requires that any organization certified by DMH develop special safety procedures that reflect the policy above. Mechanical restraints are prohibited. Additionally, procedures must be developed which address standards of care as required in this section.

(4) Seclusion refers to the placement of a consumer alone in any room from which the consumer is physically prevented from leaving.

(5) Restraint includes both physical restraint and chemical restraint.

(6) Physical Restraint is the direct application of physical force to a consumer without the consumer's permission to restrict his or her freedom of movement.

(7) Chemical Restraint is the use of any drug to manage a consumer's behavior in a way that reduces the safety risk to the consumer or others or to temporarily restrict the consumer's freedom of movement and is not a standard treatment dosage for the consumer's medical or psychiatric condition.

(8) Time-out means the restriction of a consumer for a period of time to a designated area from which the consumer is not physically prevented from leaving for the purpose of providing the consumer an opportunity to regain self-control.

(9) Sentinel Event is an unexpected occurrence involving a child/adolescent receiving treatment for a psychological or psychiatric illness that results in serious physical injury, psychological injury, or death (or risk thereof).

(10) The standards for restraint and seclusion do not apply in the following circumstances with the exception that the standard section that addresses staff competence and training is applicable under these circumstances:

(a) To the use of restraint associated with acute medical or surgical care.

(b) When a staff member(s) physically redirects or holds a child without the child's permission, for 15 minutes or less in outpatient/non-residential programs.

(c) To time-out less than 15 minutes in length for residential programs and under 30 minutes in length for outpatient programs implemented in accordance with the procedures described in (35)(a)-(c) of this section.

(d) To instances when the consumer is to remain in his or her unlocked room or other setting as a result of the violation of unit/program rules of regulations consistent with organizational policy(ies) and procedure(s). Organizational policies and procedures shall require that room restriction be for a specified time and be limited to no longer than 12 hours. Should the consumer decide not to comply and leave the area, seclusion/restraint cannot be instituted unless the criteria are met.

(e) To protective equipment such as helmets, and

(f) To adaptive support in response to assessed physical needs of the individual (for example, postural support, orthopedic appliances).

(11) The organization must have written policies and procedures that support the protection of consumers and reflect the following:

(a) Emphasize prevention of seclusion and restraint.

(b) Demonstrate restraint or seclusion use is limited to situations in which there is immediate, imminent risk of a child/adolescent harming self or others.

(c) Implemented only when less restrictive alternative treatment interventions have been unsuccessful or are determined not to be feasible and documented in the consumer record.

(d) Is never used as coercion, discipline, or for staff convenience.

(e) Is limited to situations with adequate, appropriate clinical justification.

(f) Is used only in accordance with a written order.

(g) Seclusion and restraint may not be used in lieu of effective communication with consumers who are deaf, hard of hearing, or have limited English proficiency. In the case of consumers who are deaf and who use sign language to communicate, restraints must be applied in a way that leaves at least one hand free to sign.

(12) Non-physical interventions are always considered the most appropriate and preferred intervention. These may include redirecting the child/ adolescent's focus, verbal de-escalation, or directing the child/ adolescent to take a time-out.

(13) Utilization of restraint, seclusion, timeouts, and other techniques associated with the safety of the consumer or used to help him/her gain emotional control shall be implemented and documented in accordance with all applicable requirements and documentation shall be maintained in the consumer record. The consumer's parent/legal guardian will be asked at intake for the frequency with which they would like such information shared with them, and consumer records shall reflect that notifications conform with requests.

(14) The initial assessment of each consumer at the time of admission or intake assists in obtaining all of the following information about the consumer that could help minimize the use of restraint or seclusion. Such information is documented in the consumer record. The program informs the family/legal guardian about use and reporting. The following information is obtained/provided:

(a) Techniques, methods, or tools that would help the consumer control his or her behavior. When appropriate, the consumer and/or family/legal guardian assist in the identification of such techniques.

(b) Pre-existing medical conditions or any physical disabilities and limitations that would place the consumer at greater risk during restraint or seclusion including developmental age and history, psychiatric condition, and trauma history.

(c) Any history of sexual or physical abuse that would place the consumer at greater psychological risk during restraint or seclusion.

(d) If the consumer is deaf and uses sign language, provision shall be made to assure access to effective communication and that techniques used will not deprive the consumer of a method to communicate in sign language.

(e) The consumer and/or family/legal guardian is informed of the organization's philosophy on the use of restraint and seclusion to the extent that such information is not clinically contraindicated.

(f) The role of the family/legal guardian, including their notification of a restraint or seclusion episode, is discussed with the consumer and, as appropriate, the consumer's family/legal guardian. An agreement will be made with the family/legal guardian at intake regarding notification.

(15) Seclusion/physical restraint may be authorized only by order of a licensed independent practitioner (LIP), preferably the one who is primarily responsible for the consumer's care or by a qualified registered nurse. The person authorizing seclusion or restraint meets the requirements and such is verifiable in the personnel records. Chemical restraint may be ordered only by a licensed physician, certified registered nurse practitioner, or licensed physician's assistant. The authorization for each instance is documented in the consumer record.

(a) A licensed independent practitioner is defined as an individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges.

(b) In Alabama such individuals include: MD, DO, licensed psychologist, licensed professional counselor, licensed certified social worker, licensed marriage and family therapist, Master's level nurse in psychiatric nursing, certified registered nurse practitioner, and physician assistant.

(c) A qualified Registered Nurse is one who has successfully completed a DMH approved psychiatric management course and who as at least one year psychiatric nursing experience.

(16) In the event that a consumer who is deaf, hard of hearing, or limited English proficient must be restrained, effective communication shall be established by a staff member fluent in the consumer's language of choice. If the consumer's preferred language is sign, the staff member shall hold an Intermediate Plus level or higher on the Sign Language Proficiency Interview or be a qualified interpreter. The manner of communication is documented in the consumer record. A consumer who is deaf must have at least one hand free during physical restraint.

(17) Orders for the use of restraint and seclusion have the following characteristics:

(a) Are limited to 1 hour.

(b) Are not written as a standing order or on an as needed basis (that is, PRN).

(c) Specify the behavioral criteria necessary to be released from seclusion/restraint. It is documented that consumers are released as soon as the behavioral criteria are met.

(18) Agency written policies and procedures require every effort to be made to terminate seclusion/restraint at the earliest time it is safe to do so. Time-limited orders do not mean that restraint or seclusion must be applied for the entire length of time for which the order is written. Efforts to terminate seclusion/restraint shall be documented in the consumer's record including when seclusion/restraint is appropriately terminated sooner than the timeframe for the order ends.

(19) When restraint or seclusion is terminated before the time-limited order expires, that original order can be used to reapply the restraint or seclusion if the individual is at imminent risk of physically harming himself or herself or others, and non-physical interventions are not effective.

(20) At the time the initial order for restraint or seclusion expires, the consumer receives an in-person re-evaluation conducted by a Licensed Independent Practitioner (LIP), preferably the one who is primarily responsible for the consumer's care or by a Qualified Registered Nurse. Documentation in the consumer record shall address all of the following requirements of the in-person evaluation:

(a) The consumer's psychological status.

(b) The consumer's psychological status.

(c) The consumer's physical status as assessed by a RN, MD, DO, CRNP, or PA.

(d) The consumer's behavior.

(e) The appropriateness of the intervention measures.

(f)Any complications resulting from the intervention.

(g) The need for continued seclusion/restraint.

(h) The need for immediate changes to the consumer's course of care such as the need for timely follow-up by the consumer's primary clinician or the need for medical, psychiatric, or nursing evaluation for needed medication changes.

(21) If the restraint or seclusion is to be continued at the time of the re-evaluation, the following procedures must be followed and documented in the consumer record:

(a) A new written order is given by a Licensed Independent Practitioner or by a Qualified Registered Nurse as defined above, preferably by the one who is responsible for the care of the consumer.

(b) When next on duty, the licensed independent practitioner evaluates the efficacy of the individual's treatment plan and works with the consumer to identify ways to help him or her regain self-control.

(c) If the order is continued past the first hour, the case responsible licensed independent practitioner will be notified within 24 hours of the consumer's status.

(22) Consumers in restraint or seclusion are monitored to ensure the individual's physical safety through continuous in- person observation by an assigned staff member who is competent, fluent in the preferred language of the consumer (spoken or signed), and trained in accordance with the standard. The items in (21) are checked and documented every 15 minutes. If the consumer is in restraint, a second staff person is assigned to observe him/her.

(23) Within 24 hours after a restraint or seclusion has ended, the consumer and staff who were involved in the episode and who are available participate in a face-to-face debriefing about each episode of restraint or seclusion. To the extent possible, the debriefing shall include:

(a) All staff involved in the intervention except when the present of a particular staff person may jeopardize the well-being of the consumer.

(b) Other staff and the consumer's personal representative(s) as specified in the notification agreement may participate in the debriefing.

(c) The facility must conduct such discussion in a language that is understood by the consumer and the consumer's personal representative(s).

(d) The debriefing must be documented in the consumer record. The debriefing is used to:

1. Identify what led to the incident and what could have been handled differently.

2. Ascertain that the consumer's physical well-being, psychological comfort, and right to privacy and communication were addressed.

3. Facilitate timely clinical follow-up with the consumer's primary therapist as needed to address trauma.

4. When indicated, modify the individual's treatment plan.

(24) Within 24 hours after a restraint or seclusion has ended or the next business day in a community-based non-residential program, appropriate supervisory staff, administrative staff, and the case responsible Licensed Independent Practitioner shall perform an administrative review. To the extent that it is possible, the review should include all staff involved in the intervention, when available. The administrative review is used to:

(a) Identify the procedures, if any, that staff are to implement to prevent any recurrence of the use of restraint or seclusion.

(b) Discuss the outcome of the intervention, including any injuries that may have resulted from the use of restraint or seclusion.

(c) Staff must document in the consumer's record that the review sessions took place and must include in that documentation the names of staff who were present for the review, names of staff excused from the review, and any changes to the consumer's treatment plan that result from the review.

(d) The review shall include particular attention to the following:

1. Multiple incidents of restraint and seclusion experienced by a consumer within a 12-hour timeframe.

2. The number of episodes for the consumer.

3. Adequacy of communication in instances of restraint or seclusion of consumers who are deaf, hard of hearing, or limited English proficient.

4. Instances of restraint or seclusion that extend beyond 2 consecutive hours.

5. The use of psychoactive medications as an alternative to, or to enable discontinuation of restraint or seclusion.

(25) In order to minimize the use of restraint and seclusion, all direct care staff as well as any other staff involved in the use of restraint and seclusion receive annual training in and demonstrate an understanding of the following before they participate in any use of restraint/seclusion:

(a) The underlying causes of threatening behaviors exhibited by the consumers they serve.

(b) That sometimes a consumer may exhibit an aggressive behavior that is related to a medical condition and not related to his or her emotional condition, for example, threatening behavior that may result from delirium in fevers, hypoglycemia.

(c) That sometimes inability to effectively communicate due to hearing loss or limited English proficiency leads to misunderstanding or increased frustration that may be misinterpreted as aggression.

(d) How their own behaviors can affect the behaviors of the consumers they serve.

(e) The use of de-escalation, mediation, self-protection and other techniques, such as time-out.

(f) Recognizing signs of physical distress in consumers who are being held, restrained, or secluded.

(g) The viewpoints of consumers who have experienced restraint or seclusion are incorporated into staff training and education in order to help staff better understand all aspects of restraint and seclusion use. Whenever possible, consumers who have experienced seclusion or restraint contribute to the training and education curricula and/or participate in staff training and education.

(26) Staff who are authorized to physically apply restraint or seclusion receive the training and demonstrate competency described in 580-2-9-.23(27). Staff who are authorized to physically apply restraint or seclusion receive annual training in and demonstrate competency every 6 months in the safe use of restraint, including physical holding techniques.

(27) Staff who are authorized to perform the 15 minute monitoring of individuals who are in restraint or seclusion receive the training and demonstrate the competence cited above and also receive ongoing training and demonstrate competence in:

(a) Taking and recording vital signs.

(b) Effective communication.

(c) Offering and providing nutrition/hydration.

(d) Checking for adequate breathing, circulation and range of motion in the extremities.

(e) Providing for hygiene and elimination needs.

(f) Providing physical and psychological comfort.

(g) Assisting consumers in meeting behavior criteria for the discontinuation of restraint or seclusion.

(h) Documenting behavior and informing clinical staff of behavior indicating readiness for the discontinuation of restraint or seclusion.

(i) Recognizing when to contact a medically trained licensed independent practitioner or emergency medical services.

(j) Recognizing signs of injury associated with seclusion and restraint.

(k) Recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which an individual reacts to physical contact.

(l) Recognizing the behavior criteria for the discontinuation of restraint or seclusion.

(m) Records of initial and ongoing staff training and competency testing shall be maintained in personnel records and training materials shall be available for review as needed.

(28) All direct care staff are competent to initiate first aid and cardiopulmonary resuscitation. Records of staff training shall be maintained in personnel records.

(29) There is a written plan for provision of emergency medical services. Consumer records demonstrate that appropriate medical services were provided in an emergency.

(30) Restraint and seclusion shall:

(a) Be implemented in a manner that protects and preserves the rights, dignity, and well-being of the child/adolescent.

(b) Be implemented in the least restrictive manner possible in accordance with safe, appropriate restraining techniques.

(c) Not be used as punishment, coercion, discipline, retaliation, for the convenience of staff, or in a manner that causes undue physical discomfort, harm, or pain.

(31) Consumer records document that the use of restraint or seclusion is consistent with organization policy, and documentation focuses on the individual. Each episode of use is recorded. Documentation includes:

(a) The circumstances that led to their use.

(b) Consideration or failure of non-physical interventions.

(c) That consumers who are deaf or limited English proficient are provided effective communication in the language that they prefer (signed or spoken) during seclusion and restraint.

(d) The rationale for the type of physical intervention selected.

(e) Notification of the individual's family/legal guardian consistent with organizational policy and the agreement with the family/legal guardian.

(f) Specification of the behavioral criteria for discontinuation of restraint or seclusion, informing the consumer of the criteria, and assistance provided to the consumer to help him or her meet the behavioral criteria for discontinuation.

(g) Each verbal order received from a physician, certified registered nurse practitioner, or physician's assistant must be signed within 48 hours.

(h) Each in-person evaluation of the consumer signed by the staff person who provided the evaluation.

(i) Continuous monitoring to include 15-minute assessments of the consumer's status.

(j) Debriefing of the individual with staff.

(k) Any injuries that are sustained and treatment received for these injuries.

(l) Circumstances that led to death.

(32) Staffing numbers and assignments are adequate to minimize circumstances leading to seclusion and restraint and to maximize safety when restraint and seclusion are used. Staff qualification, the physical design of the facility, the diagnoses and acuity level of the residents, age, gender, and developmental level of the residents shall be the basis for the staffing plan.

(33) The provider must report the use of seclusion and restraint to DMH in accordance with published reporting guidelines. Additionally, the organization is required by applicable law and regulations to report injuries and deaths to external agencies.

(34) The provider must demonstrate that procedures are in place to properly investigate and take corrective action where indicated and where seclusion and restraint results in consumer injury or death.

(35) Time-out shall be implemented as follows:

(a) A consumer in time-out must never be physically prevented from leaving the time-out area.

(b) Time-out may take place away from the area of activity or from other consumers such as in the consumer's room (exclusionary) or in the area of activity of other consumers (inclusionary).

(c) Staff must monitor the consumer while he or she is in time-out.

(d) Documentation shall support that these procedures were followed and shall include the following:

1. Circumstances that lead to the use of time-out regardless of whether the time-out was consumer requested, staff suggested, or staff directed.

2. Name and credentials of staff who monitored the consumer throughout the time-out.

3. Where on the provider's premises either an inclusionary or an exclusionary time-out was implemented.

4. The length of time for which time-out was implemented.

5. Behavioral or other criteria for release from time-out if applicable.

6. The status of the consumer when time-out ended.

Notes

Ala. Admin. Code r. 580-2-9-.23

New Rule: Filed June 14, 2010; effective July 19, 2010.

Author: Division of Mental Illness, DMH

Statutory Authority: Code of Ala. 1975, § 22-50-11.