Behavior Management Requirements for the Use of Manual Restraints

Section 384 Section 384.50  Behavior Management Requirements for the Use of Manual Restraints Each application of manual restraint may be used only as a therapeutic measure when a child presents a threat of physical harm to self or others.  Such threat shall include any dangerous behavior reasonably expected to lead to physical harm to self or others. Manual restraint shall not be used until after other less restrictive procedures or measures have been explored and found to be inappropriate. Manual restraint shall not be used for a child whose medical condition, mental illness, or developmental or psychological status contraindicates the use of this technique, as documented in the child's individual treatment plan. a)         Manual restraint may be used to prevent runaway only when the child presents a threat of physical harm to self or others, or as specified in the individual treatment plan. b)         Manual restraint shall not be used as discipline for rule infractions or as a convenience for staff. c)         A child may not be restrained for more than 15 minutes beyond the point at which the child ceases presenting the specific behavior for which the restraint was ordered or any other behavior for which restraint is an appropriate intervention, unless specific clinical justification to the contrary is documented in the child's treatment plan. d)         For every restraint episode that exceeds 30 consecutive minutes, a registered nurse or a licensed physician must be notified and consulted by telephone or in person concerning the restraint. The licensed physician or registered nurse must confirm, in writing, the content of the consultation and document that the restraint does not pose an undue risk to the child's health given the child's physical or medical condition.  At the same time, the treatment team must explore alternative treatment strategies, such as an emergency SASS assessment or transporting the child to a hospital or mental health facility. e)         No child may be restrained for more than two hours within a 24 hour period. However, within the two hours of restraint, there may be no period of continuous restraint that exceeds one hour. f)         If a child has been in and out of manual restraint for a total of two hours, the treatment team must explore alternative treatment strategies, such as an emergency SASS assessment or transporting the child to a hospital or mental health facility. g)         Manual restraint shall be administered in such a manner as to avoid provoking further and escalating incidents of the behavior in the child. h)         Manual restraint shall not consist of, or be accompanied by, the use of mechanical restraints, the use of excessive or unnecessary force, or any other action that produces pain, covers the head or any part of the face, or in any way restricts normal circulation and respiration of the child. Manual restraints that include neck holds or a staff member lying across the torso of a client are prohibited. i)          When manual restraint is imposed upon any child whose primary mode of communication is sign language, the child shall be permitted to have his or her hands free from restraint for brief periods during the restraint, except when such freedom may result in physical harm to the child or others. j)          Manual restraint shall be employed only by persons who are certified as having successfully completed a competency based training program presenting the specific procedures to be used.  This certification must be renewed through a competency based assessment at least every 12 months. Current certification of competency shall be documented in the individual's permanent personnel record.  If an organized self-governance program, as defined in Section 384.20, approved by the governing body and the Department allows for peer participation, only peers having completed such training may assist with the technique.  This training shall include demonstrated competency in the humane and efficient implementation of the restraint program as demonstrated in applications of the procedures on participants in the training. k)         Application of manual restraint requires direct authorization, supervision and management by the mental health professional, as defined in Section 384.20, designated as responsible for making clinical decisions at the time restraint is applied.  If this person is not present when restraint is first applied, he or she must be summoned immediately and maintain supervision and management of the restraint until the restraint episode is concluded or he or she is relieved by a similarly qualified and clinically responsible person.  Supervision of a restraint episode does not require in person supervision throughout the duration of the restraint provided that the mental health professional has viewed the restraint in person, has confirmed that the restraint is being applied according to the agency's selected model and is confident that the restraint will continue to be so applied. The mental health professional must review the restraint episode immediately upon conclusion of the restraint to ensure that the restraint continued and concluded in a manner that is consistent with the model and the child's interest. Each use of manual restraint shall be reported as soon as practicable and a written record forwarded within 24 hours to the administrator of the facility or designee, the assigned caseworker in the facility, and the social work supervisor.  If the use of manual restraint results in an injury requiring emergency medical treatment by medical personnel or exceeds 60 consecutive minutes, the senior agency administrator shall be contacted immediately. l)          The written record of manual restraint shall include: the date of the occurrence; the precipitating incidents; the age, height, weight, sex and race of the restrained child; the persons (including other residents) who participated in restraining the child; any witnesses to the precipitating incident and subsequent restraint; the exact methods of restraint used; the beginning and ending time of the restraint; a detailed description of any injury arising from the incident or restraint; and a summary of any medical care provided.  The supervisor in charge at the time of the incident and restraint shall review the report submitted by staff, inquire into any irregularities, and sign and date the written report indicating the date it was reviewed and approved or disapproved. m)        The administrator of the facility or designee shall review all written records of manual restraint the next business day.  The administrator or designee shall approve or disapprove of the use of restraint under the circumstances described and shall indicate review and approval/disapproval by signing and dating the report of behavior treatment.  If the administrator or designee disapproves of this instance of manual restraint, the administrator or designee shall state the reasons for disapproval and shall correct the improper use of manual restraint.  The decision concerning the need for further action, if any, should be documented whenever any of the following occurs: 1)         restraint is used repeatedly excessively by any staff person; 2)         restraint is used repeatedly excessively on any child; 3)         the duration of the restraint exceeds 30 minutes; 4)         any provision in this Part is violated; or 5)         the restraint results in any injury requiring emergency medical treatment by medical personnel. n)         Upon request, the administrator of the facility or designee shall notify the child's parents (unless parental rights have been terminated), guardian or attorney in writing, within two business days, when a child is subjected to manual restraint, and shall provide such notice for any manual restraint that results in injury to the child within 12 hours. Communication to the child's parent or guardian shall be conducted in the parent's or guardian's primary language or preferred mode of communication.