Emergency safety interventions

The facility shall provide and administer emergency safety interventions as follows: 1. For purposes of this section: a. "Drug used as a restraint" means any drug that: (1) Is administered to manage a resident's behavior in a way that reduces the safety risk to the resident or others; (2) Has the temporary effect of restricting the resident's freedom of movement; and (3) Is not a standard treatment for the resident's medical or psychiatric condition. b. "Emergency safety intervention" means the use of restraint as an immediate response to an emergency safety situation involving unanticipated resident behavior that places the resident or others at threat of serious violence or serious injury if no intervention occurs. c. "Emergency safety situation" means a situation where immediate risk of harm is present due to unanticipated resident behavior that places the resident or others at threat of serious violence or serious injury if no intervention occurs and that calls for an emergency safety intervention as defined in this section. d. "Personal restraint" means the application of physical force without the use of any device, for the purposes of restraining the free movement of a resident's body. The term personal restraint does not include briefly holding without undue force a resident to calm or comfort him or her, or holding a resident's hand to safely escort a resident from one area to another, or a physical escort which means a temporary touching or holding of the hand, wrist, arm, shoulder, or back for the purpose of inducing a resident who is acting out to walk to a safe location. e. "Tier 2 mental health professional" has the same meaning as the term defined in subsection 9 of North Dakota Century Code section 25-01-01. 2. Education and training related to emergency safety interventions: a. Individuals who are qualified by education, training, and experience shall provide employee education and training. b. Employees must be trained and demonstrate competency before participating in an emergency safety intervention. c. The facility shall document in the employee personnel records that the training and demonstration of competency were successfully completed. d. All training programs and materials used by the facility must be available for review by the accreditation body and the state agency. e. The facility shall require employees to have ongoing education, training, and demonstrated knowledge and competency of all of the following, no less than semiannually: (1) Techniques to identify employee and resident behaviors, events, and environmental factors that may trigger emergency safety situations; (2) The use of nonphysical intervention skills, such as de-escalation, mediation conflict resolution, active listening, and verbal and observational methods, to prevent emergency safety situations; (3) The safe use of restraint, including the ability to recognize and respond to signs of physical distress in residents who are restrained; and (4) Training exercises in which employees successfully demonstrate in practice the techniques they have learned for managing emergency safety situations. 3. Emergency safety intervention: a. Facilities shall have a policy for the safe use of emergency safety interventions; b. Restraint may be used only when a resident poses an immediate threat of serious violence or serious injury to self or others and must be discontinued when the immediate threat is gone; c. Employees shall document all interventions attempted to de-escalate a resident before the use of a restraint; d. When restraint is deemed appropriate, personal restraint is allowed; e. Mechanical restraints, prone restraints, and drugs or chemicals used as a restraint are prohibited; f. The use of seclusion by the facility is prohibited; g. Employee training requirements must include procedures: (1) For when restraint may and may not be used; (2) That safeguard the rights and dignity of the resident; (3) For obtaining informed consent, including the right of the custodian and parent or guardian of the resident to be notified of any use of restraint or any change in policy or procedure regarding use; (4) Regarding documentation requirements of each restraint episode and the use of such data in quality improvement activities; and (5) Regarding the debriefing of the resident and employees immediately after incidents of restraint; and f. Quality management activities must examine the following: (1) Available data on the use of these practices and their outcomes, including the frequency of the use of restraint, settings, authorized employees, and programs; (2) The accuracy and consistency with which restraint data is collected, as well as the extent to which restraint data is being used to plan behavioral interventions and employee training; (3) Whether policies and procedures for using these practices are being implemented with fidelity; (4) Whether procedures continue to protect residents; and (5) Whether existing policies for restraint remain properly aligned with applicable state and federal laws. 4. Personal restraint: a. Personal restraint is the only form of restraint allowed. b. If an emergency safety situation occurs and a personal restraint is determined necessary, the following actions are prohibited: (1) Any maneuver or techniques that do not give adequate attention and care to protection of the resident's head; (2) Any maneuver that places pressure or weight on the resident's chest, lungs, sternum, diaphragm, back, or abdomen causing chest compression; (3) Any maneuver that places pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the resident's head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, such as straddling or sitting on the resident's torso; (4) Any type of choke hold; (5) Any technique that uses pain inducement to obtain compliance or control, including punching, hitting, hyperextension of joints, or extended use of pressure points for pain compliance; and (6) Any technique that involves pushing on or into a resident's mouth, nose, or eyes, or covering the resident's face or body with anything, including soft objects, such as pillows, washcloths, blankets, and bedding. 5. Authorization for the use of restraint: a. Authorization for restraint must be given by a tier 2 mental health professional and the tier 2 mental health professional must be trained in the use of the facility emergency safety interventions. b. The authorization must indicate the least restrictive emergency safety intervention that is most likely to be effective in resolving the emergency safety situation based on consultation with the clinical director. c. If the authorization for restraint is verbal, the verbal authorization must be received by a clinical team member, while the emergency safety intervention is being initiated by an employee or immediately after the emergency safety situation ends. The tier 2 mental health professional must verify the verbal authorization in a signed written form in the resident's record and be available to the resident's treatment team for consultation, in person or through electronic means, throughout the period of the emergency safety intervention. d. Each authorization for restraint: (1) Must be limited to no longer than the duration of the emergency safety situation; (2) May not exceed the amount of time necessary to begin verbal de-escalation techniques with the resident; and (3) Must be signed by the tier 2 mental health professional no later than twelve hours from initiation of a verbal authorization. e. Within one hour of the initiation of a restraint, a face-to-face assessment of the physical and psychological well-being of the resident must be completed, documenting: (1) The resident's physical and psychological status; (2) The resident's behavior; (3) The appropriateness of the intervention measures; and (4) Any complications resulting from the intervention. f. Each authorization for restraint must include: (1) The name of the tier 2 mental health professional; (2) The date and time the authorization was obtained; and (3) The emergency safety intervention authorized, including the length of time authorized. g. An employee shall document the intervention in the resident's record. That documentation must be completed by the end of the shift in which the intervention occurs. If the intervention does not end during the shift in which it began, documentation must be completed during the shift in which it ends. Documentation must include all of the following: (1) Each authorization for restraint as required in subdivision f; (2) The time the emergency safety intervention began and ended; (3) The time and results of the one-hour assessment required in subdivision e; (4) The detailed emergency safety situation that required the restraint; and (5) The name of each employee involved in the restraint intervention. h. The facility must maintain a record of each emergency safety situation, the interventions used, and their outcomes. i. If a tier 2 mental health professional authorizes the use of restraint, that individual shall: (1) Consult with the resident's prescribing physician as soon as possible and inform the resident's physician of the emergency safety situation that required the restraint; and (2) Document in the resident's record the date and time the resident's prescribing physician was consulted. 6. Monitoring of the resident in and immediately after restraint: a. An on-call clinical team member trained in the use of emergency safety interventions shall be physically present, continually assessing and monitoring the physical and psychological well-being of the resident and the safe use of restraint throughout the duration of the emergency safety intervention. b. If the emergency safety situation continues beyond the time limit of the authorization for the use of restraint, a nurse or other on-call clinical team member, immediately shall contact the tier 2 mental health professional, to receive further instructions. c. Upon completion of the emergency safety intervention, the resident's well-being must be evaluated immediately after the restraint has ended. 7. Notification of custodian and parent or guardian: a. The facility shall notify the custodian and parent or guardian of the resident who has been restrained as soon as possible after the initiation of each emergency safety intervention. b. The facility shall document in the resident's record that the custodian and parent or guardian has been notified of the emergency safety intervention, including the date and time of notification and the name of the employee providing the notification. 8. Postintervention debriefings: a. Within twenty-four hours after the use of restraint, employees involved in an emergency safety intervention and the resident shall have a face-to-face discussion. This discussion must include all employees involved in the intervention except when the presence of a particular employee may jeopardize the well-being of the resident. Other employees and the custodian and parent or guardian may participate in the discussion when it is deemed appropriate by the facility. The facility shall conduct such discussion in a language understood by the custodian and parent or guardian. The discussion must provide all parties the opportunity to discuss the circumstances resulting in the use of restraint and strategies to be used by the facility, the resident, or others who could prevent the future use of restraint. b. Within twenty-four hours after the use of restraint, all employees involved in the emergency safety intervention, and appropriate supervisory and administrative leadership, shall conduct a debriefing session that includes, at a minimum, a review and discussion of: (1) The emergency safety situation that required the emergency safety intervention, including a discussion of the precipitating factors that led up to the emergency safety intervention; (2) Alternative techniques that might have prevented the use of the restraint; (3) The procedures, if any, employees are to implement to prevent any recurrence of the use of restraint; and (4) The outcome of the emergency safety intervention, including any injuries that may have resulted from the use of restraint. c. An employee shall document in the resident's record that both debriefing sessions took place and shall include in that documentation the names of employees who were present for the debriefing, names of employees excused from the debriefing, and any changes to the resident's treatment plan that resulted from the debriefings.