Ga. Comp. R. & Regs. R. 111-8-68-.08 - Behavior Management and Emergency Safety Interventions

(1) Behavior Management.

(a) The facility shall develop and implement policies and procedures on behavior management. Such policies and procedures shall set forth the types of patients served in accordance with its program purpose, the anticipated behavioral problems of the patients, and acceptable methods of managing such problems.

(b) Such behavior management policies and procedures shall incorporate the following minimum requirements:

1. Behavior management principles and techniques shall be used in accordance with the individual treatment plan, written policies and procedures, treatment goals, safety, security, and these rules and regulations.

2. Behavior management shall be limited to the least restrictive appropriate method, as described in the patient's treatment plan, and in accordance with the prohibitions as specified in these rules and regulations.

3. Behavior management principles and techniques shall be administered by facility staff members and shall be appropriate to the severity of the patient's behavior, chronological and developmental age, size, gender, physical, medical, psychiatric condition, and personal history (including any history of physical or sexual abuse).

(c) The following forms of behavior management shall not be used by staff members with patients receiving services from the facility:

1. assignment of excessive or unreasonable work tasks;

2. denial of meals and hydration;

3. denial of sleep;

4. denial of shelter, clothing, or essential personal needs;

5. denial of essential program services;

6. verbal abuse, ridicule, or humiliation;

7. restraint, manual holds, and seclusion used as a means of coercion, discipline, convenience, or retaliation;

8. denial of communication and visits unless restricted in accordance with Rule 111-8-68-.06(i)(2); and

9. corporal punishment.

(d) Patients shall not be permitted to participate in the behavior management of other patients or to discipline other patients, except as part of an organized therapeutic self-governing program in accordance with accepted standards of clinical practice that is conducted in accordance with written policy and is supervised directly by designated staff.

(2) Emergency Safety Interventions.

(a) Emergency safety interventions shall only be used when a patient exhibits a dangerous behavior reasonably expected to lead to immediate physical harm to the patient or others and less restrictive means of dealing with the injurious behavior have not proven successful or may subject the patient or others to greater risk of injury.

(b) Any emergency safety intervention involving use of mechanical restraints, manual holds, or seclusion must be ordered by a physician or other licensed professional trained in emergency safety interventions and authorized by State law to order such use.

1. The order may not be a standing order or on an as-needed basis.

2. If the order is a verbal order, it must be received by a licensed nurse or otherwise qualified staff as determined by the medical staff in accordance with State law, prior to initiation of the emergency safety intervention, while the intervention is being initiated by staff, or immediately thereafter. The individual issuing the order must verify the verbal order in a signed written form in the patient's record within the timeframe designated by facility policy and procedure which ensures that it is done as soon as possible. The individual ordering the use of the intervention must be available to staff for consultation, at least by a two-way communication device, throughout the course of the emergency safety intervention.

3. Each order for use of restraint or seclusion must be limited to no longer than the duration of the emergency safety situation.

4. Each order for the use of mechanical restraint, manual hold, or seclusion, must include the name of the physician or other licensed professional, the date and time the order was obtained, the type of intervention ordered, and the length of time for which the use of the intervention was authorized. Restraint and seclusion orders shall not exceed:

(i) four (4) hours for patients ages 18 to 21;

(ii) two (2) hours for patients ages 9 to 17;

(iii) one (1) hour for patients under age 9; and

(iv) fifteen (15) minutes for manual holds with one order renewal for an additional fifteen(15) minutes for a total of thirty (30) minutes.

5. If the emergency safety situation continues beyond the time limit authorized in the order, a registered nurse or other licensed professional must immediately contact the ordering physician or the ordering licensed professional to receive further instructions.

(c) Emergency safety interventions shall not include the use of any restraint or manual hold that would potentially impair the patient's ability to breathe or has been determined to be inappropriate for use on a particular patient due to a documented medical or psychological condition.

(d) The facility shall have written policies and procedures for the use of emergency safety interventions, a copy of which shall be provided to and discussed with each patient (as appropriate taking into account the patient's age and intellectual development) and the patient's parents and/or legal guardians prior to or at the time of admission. Emergency safety interventions policies and procedures shall include:

1. requirements for the documentation of an assessment at admission and at each annual exam by the patient's physician, a physician's assistant, or a registered nurse with advanced training working under the direction of a physician, which reflects that there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that patient. Such assessment and documentation must be reevaluated following any significant change in the patient's medical condition;

2. requirements for prohibiting the use of mechanical restraints, manual holds, or seclusion use by any employee not trained in prevention and use of emergency safety interventions, as required by these rules; and

3. requirements that all actions taken that involve utilizing an emergency safety intervention shall be recorded in the patient's record, including at a minimum the following:

(i) date and description of the precipitating incident;

(ii) the order for use of any mechanical restraints, manual hold, or seclusion;

(iii) description of the de-escalation techniques used prior to the emergency safety intervention, if applicable;

(iv) environmental considerations;

(v) names of staff participating in the emergency safety intervention;

(vi) any witnesses to the precipitating incident and subsequent intervention;

(vii) exact emergency safety intervention used;

(viii) evidence of the continuous visual monitoring of a patient in mechanical restraint, manual hold, or seclusion, documented minimally at fifteen (15) minute intervals;

(ix) the provision of fluids every hour, food at regular intervals, and bathroom breaks every two (2) hours;

(x) beginning and ending time of the intervention;

(xi) outcome of the intervention;

(xii) detailed description of any injury arising from the incident or intervention; and

(xiii) summary of any medical care provided.

(e) Emergency safety interventions may be used to prevent runaways only when the patient presents an imminent threat of physical harm to self or others, or as specified in the individual treatment plan.

(f) Facility staff shall be aware of each patient's known or apparent medical and psychological conditions (e.g. obvious health issues, list of medications, history of physical abuse, etc.), as evidenced by written acknowledgement of such awareness, to ensure that the emergency safety intervention that is utilized does not pose any undue danger to the physical or mental health of the patient.

(g) Patients shall not be allowed to participate in the emergency safety intervention of another patient.

(h) Within one (1) hour of the initiation of an emergency safety intervention and immediately following the conclusion of the emergency safety intervention, a physician or other licensed independent practitioner; or a registered nurse or physician assistant; trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological well-being of patients must conduct a face-to-face assessment of the patient. The assessment at a minimum must include:

1. the patient's physical and psychological status;

2. the patient's behavior;

3. the appropriateness of the intervention measures; and

4. any complications and treatments resulting from the intervention.

(i) Manual Holds.

1. Emergency safety interventions utilizing manual holds require at least one (1) trained staff member to carry out the hold. Emergency safety interventions utilizing prone restraints require at least two trained staff members to carry out the hold.

2. When a manual hold is used upon any patient whose primary mode of communication is sign language, the patient shall be permitted to have his or her hands free from restraint for brief periods during the intervention, except when such freedom may result in physical harm to the patient or others.

3. A manual hold requires physician authorization at fifteen (15) minute intervals and may not be used for more than thirty (30) minutes at any one time without the consultation of the ordering physician or other licensed professional authorized to order the use of manual holds. The ordering physician or other licensed professional authorized to order the use of the hold shall be contacted by a two-way communications device or in person to determine that the continuation of the manual hold is appropriate under the circumstances.

4. If the use of a manual hold on a patient reaches a total of one hour within a twenty-four (24) hour period, the staff shall reconsider alternative treatment strategies, and document same.

5. The patient's breathing, verbal responsiveness, and motor control shall be continuously monitored during any manual hold. Documentation of the monitoring by a trained staff member shall be recorded every fifteen (15) minutes during the duration of the restraint.

(j) Seclusion.

1. A room used for the purposes of seclusion must meet the following criteria:

(i) The room shall be constructed and used in such ways that the risk of harm to the patient is minimized;

(ii) The room shall be equipped with a viewing window so that staff can monitor the patient;

(iii) The room shall be lighted and well-ventilated;

(iv) The room shall be a minimum fifty (50) square feet in area; and

(v) The room must be free of any item that may be used by the patient to cause physical harm to himself/herself or others.

2. No more than one (1) patient shall be placed in the seclusion room at a time.

3. A seclusion room monitoring log shall be maintained and used to record the following information:

(i) name of the secluded patient;

(ii) reason for the patient's seclusion;

(iii) time of patient's placement in the seclusion room;

(iv) name and signature of the staff member that conducted visual monitoring;

(v) signed observation notes; and

(vi) time of the patient's removal from the seclusion room.

(k) Training, Evaluation, and Reporting.

1. All facility staff members who may be involved in the use of emergency safety interventions, shall have evidence of having satisfactorily completed a nationally recognized training program for emergency safety interventions to protect patients and others from injury, which has been taught by an appropriately certified trainer in such program. Emergency safety interventions may only be used by those staff members who have received such training and successfully demonstrated the techniques learned for managing emergency safety situations.

2. At a minimum, the emergency safety intervention program that is utilized shall include the following:

(i) techniques for de-escalating problem behavior including patient and staff debriefings;

(ii) appropriate use of emergency safety interventions;

(iii) recognizing aggressive behavior that may be related to a medical condition;

(iv) awareness of physiological impact of a restraint on the patient;

(v) recognizing signs and symptoms of positional and compression asphyxia and restraint associated cardiac arrest;

(vi) instructions as to how to monitor the breathing, verbal responsiveness, and motor control of a patient who is the subject of an emergency safety intervention;

(vii) appropriate self-protection techniques;

(viii) policies and procedures relating to using manual holds, including the prohibition of any technique that would potentially impair a patient's ability to breathe;

(ix) facility policies and reporting requirements;

(x) alternatives to restraint;

(xi) avoiding power struggles;

(xii) escape and evasion techniques;

(xiii) time limits for the use of restraint and seclusion;

(xiv) process for obtaining approval for continual restraints and seclusion;

(xv) procedures to address problematic restraints;

(xvi) documentation;

(xvii) investigation of injuries and complaints;

(xviii) monitoring physical signs of distress and obtaining medical assistance; and

(xix) legal issues.

3. Emergency safety intervention training shall be in addition to the training required in Rule 111-8-68-.05(5)(d) and shall be documented in the staff member's personnel record.

4. The facility shall take and document appropriate corrective action when it becomes aware of or observes the inappropriate use of an emergency safety intervention technique as outlined in these rules and regulations and shall notify each patient's parents and/or legal guardians. Documentation of the incident and the corrective action taken by the facility shall be maintained.

(l) At least monthly, the facility, utilizing a master restraint/seclusion log and the patients' records, shall review the use of all emergency safety interventions for each patient and staff member, including the type of intervention used and the length of time of each use, to determine whether there was a clinical basis for the intervention, whether the use of the emergency safety intervention was warranted, whether any alternatives were considered or employed, the effectiveness of the intervention or alternative, and the need for additional training. Written documentation of all such reviews shall be maintained. Where the facility identifies opportunities for improvement as a result of such reviews or otherwise, the facility shall implement these changes through an effective quality improvement plan designed to reduce the use of emergency safety devices.

(m) Facilities shall submit to the department electronically or by facsimile a report, within twenty-four (24) hours, whenever the facility becomes aware of an incident which results in any injury of a patient requiring medical treatment beyond first aid that is received by a patient as a result of or in connection with any emergency safety intervention. In addition facilities must report the following:

1. For any thirty (30) day period, where three (3) or more incidents for the same patient occur where the facility has used mechanical restraint or seclusion lasting four (4) or more hours for patients ages 18-21; two (2) or more hours for patients ages 9 to 17; or one (1) or more hours for patients under nine (9) years of age and/or when three (3) or more incidents for the same patient occur where the facility has used manual holds lasting thirty (30) or more minutes. The reports shall include the type of emergency safety intervention, total amount of time in the intervention, and any actions taken to prevent further use of emergency safety interventions.

2. On a monthly basis, the total number of emergency safety interventions shall be reported by patient unit, including the total amount of time each intervention was used, and the monthly average daily census for each unit. The report shall include a summary of the facility's monthly evaluation of their use of emergency safety interventions, including actions taken.

Notes

Ga. Comp. R. & Regs. R. 111-8-68-.08

O.C.G.A. Secs. 31-2-9, 31-7-2.1.

Original Rule entitled "Behavior Management and Emergency Safety Interventions" adopted. F. July 14, 2010; eff. August 3, 2010.