Code of Massachusetts Regulations
104 CMR - DEPARTMENT OF MENTAL HEALTH
Title 104 CMR 28.00 - Licensing and Operational Standards for Community Services
Subpart A - STANDARDS FOR COMMUNITY SERVICES
Section 28.05 - Prohibition of Medication Restraint and Mechanical Restraint or Seclusion; Prevention of Physical Restraint; and Requirements for Emergency Physical Restraint When Necessary

Universal Citation: 104 CMR 28.00 MA Code of Regs 28.05

Current through Register 1531, September 27, 2024

(1) Medication restraint, mechanical restraint or seclusion shall not be used. Physical restraint may only be used in an emergency and if the requirements of 104 CMR 28.05(4) are met.

(2) Physical restraint occurs when a manual method is used to restrain a person by restricting the person's freedom of movement or normal access to his or her body. Physical restraint does not include taking reasonable steps to prevent a person at imminent risk of entering a dangerous situation from doing so with a limited response to avert injury, such as blocking a blow, breaking up a fight, or preventing a fall, a jump, or a run into traffic.

(3) Prevention of the Use of Physical Restraint. Each provider shall develop and implement a strategic plan to prevent, reduce, and wherever possible eliminate, the use of physical restraint in its service. A provider's plan shall include, at a minimum, the following:

(a) policies and procedures supporting the prevention, reduction and, wherever possible, elimination of physical restraint;

(b) staff training focusing on:

1. crisis prevention and de-escalation; and

2. the safe and appropriate use of physical restraint in the event of imminent danger.

(c) the development of a supportive environment that incorporates the teaching of and use of coping skills and strategies, including sensory integration/modulation approaches to prevent, reduce, and wherever possible eliminate the use of physical restraints;

(d) the development and use of individual crisis prevention plans for all persons;

(e) the development and use of debriefing procedures following an episode of restraint to address, at a minimum, what led to the incident, what might have prevented or curtailed the incident, and how to prevent future incidents. Debriefing activities shall at a minimum include:

1. identification of what led to the episode;

2. determination of whether the individual crisis prevention plan was used;

3. assessment of alternative interventions that may have avoided the use of restraint;

4. determination of whether the person's physical and psychological needs were appropriately addressed and that the person's right to privacy was maintained;

5. whether the restraint resulted in any injuries and the results of such injuries;

6. consideration of counseling or medical evaluation and treatment for the involved person and/or staff for any emotional or physical trauma that may have resulted from the incident;

7. consideration of whether other persons and staff who may have witnessed or otherwise been affected by the incident should be involved in debriefing activities or offered counseling;

8. determination of whether the legally authorized representative, if any, family members, or others should be notified of and/or involved in debriefing activities;

9. consideration of whether additional supervision or training should be provided to staff involved in the incident;

(f) documentation requirements that will ensure an adequate record of the authorization, the less restrictive means attempted, if any, and the reason for their failure and all debriefing activities. These requirements must, at a minimum, meet the documentation requirements set forth in 104 CMR 28.05(4);

(g) requirement that debriefings documentation be reviewed by appropriate staff for the purpose of identifying and addressing opportunities to prevent, reduce, or eliminate future occurrences of restraint;

(h) appropriate review of the use of physical restraint by senior administrative and clinical staff;

(i) the process for understanding and addressing any person's concern or complaint about the use of physical restraint;

(j) the use of data to monitor and improve quality and prevent, reduce, and wherever possible eliminate the use of restraint, such as identifying times or shifts with a high incidence of restraint, and to modify the plan as indicated;

(k) the identification and utilization of support measures after a restraint, including debriefing activities which may include peer support, advocacy, Human Rights Officer participation and inclusion of family and friends designated by the person; and

(l) the provider's strategic plan to prevent, reduce, and wherever possible eliminate, the use of physical restraint in its service must be reviewed and updated in the event there are repeated instances of restraint at the site, but no less frequently than on an annual basis.

(4) Emergency Physical Restraint.

(a) Emergency physical restraint may be used only under the following conditions:

1. In the presence of an emergency where there is a substantial, imminent risk of, or the occurrence of, serious self-destructive behavior, or serious physical assault;

2. A substantial risk includes only the serious imminent threat of bodily harm where there is the present ability to enact such harm, including instances where property damage may result in bodily harm;

3. Less restrictive alternatives, including strategies identified in the person's crisis prevention plan or treatment plan, if any, have been tried and failed, or a determination has been made that such alternatives would be inappropriate or ineffective under the circumstances; and

4. Written authorization for the use of physical restraint has been obtained from the Director or an administrator designated to act on his or her behalf.

a. Where neither person is available, staff who have been trained in the program's restraint reduction and de-escalation protocols and who have been authorized by the Director may initiate the emergency restraint prior to obtaining written authorization from the Director in the event a physician is not on site, provided the authorization of the Director or the designee is obtained immediately thereafter, and in no event later than four hours after the initial occurrence.

b. The authorization shall be dated and recorded in the person's record.

5. Authorization for "as needed" or "as required" ("PRN") restraint may not be ordered in any circumstance.

(b) If emergency physical restraint is used:

1. It may only include bodily holding of a person with no more force than necessary to limit a person's movement;

2. It may be used only for the purpose of preventing the continuation or renewal of such emergency condition and only to the minimum extent and duration necessary. No emergency restraint may last longer than 15 minutes and nursing staff must be available to monitor and resolve the crisis.

3. It shall be employed to allow the person the greatest possible comfort and to avoid physical injury and mental distress;

4. The person being restrained shall be held or placed in a position that allows airway access and does not compromise respiration. A face-down position shall not be used, unless:

a. there is a specified preference by the person and no psychological or medical contraindication to its use; or

b. there is an overriding psychological or medical justification for its use, which shall be documented.

5. A staff debriefing shall be conducted in accordance with the provider's plan for prevention of the use of emergency physical restraint. The person who was subject to physical restraint shall separately be asked to debrief. These debriefings shall occur as soon as possible after the restraint.

6. A youth debriefing shall be conducted in accordance with the provider's strategic plan for the prevention of the use of emergency physical restraint. The youth's legally authorized representative, if any, shall be invited to participate in the debriefing process. Subject to the legally authorized representative's consent, the youth may invite others such as preferred staff or another family member to attend the debriefing and participate in the process. The intent of the debriefing is to learn about the circumstances that contributed to the restraint, heal the breach in the therapeutic alliance, and adjust the treatment plan or crisis prevention plan to prevent recurrence.

1. A description of the restraint;

2. The reason for the restraint;

3. Whether the person's crisis prevention plan was followed;

4. The types of less restrictive alternatives, including sensory interventions, if any, which were attempted before the use of physical restraint, and if none were attempted, the reason(s) why.

5. The name of the staff person authorizing the restraint and of all staff involved in the restraint;

6. The time or times the restraint was used;

7. The duration of the restraint;

8. Any subsequent revisions to the person's treatment plan or crisis prevention plan as a result of the restraint episode;

9. Documentation of communication to inform staff, legally authorized representative, and others involved in the event regarding the episode of restraint, as well as any subsequent changes in the person's treatment plan or crisis intervention plan as a result of the episode; and

10. A summary of the debriefing activities.

(d) If emergency physical restraint is used, the Director or designee shall ensure there is a timely review of the person's treatment plan and crisis prevention plan as applicable to evaluate the need for appropriate clinical interventions. If the person experiences the use of physical restraint for a period greater than 15 minutes or more than one physical restraint within a 24-hour period, the Director or designee shall initiate the review immediately.

(e) Notifications; Monthly Reports; Human Rights Committee Review.

1. The person's legally authorized representative, if any, shall be notified of the physical restraint as soon as possible, but no later than the next business day.

2. The service's Human Rights Officer shall be notified of the physical restraint as soon as possible, but no later than the next business day.

3. At the end of any month in which physical restraint was utilized in a service, the Director shall submit a report to the Human Rights Committee on the nature and frequency of physical restraint in the service during that month.

a. A copy of this report shall be kept on file at the applicable service site or at the provider's administrative office;

b. The Human Rights Committee shall review the report to determine if there has been an inappropriate reliance on the use of restraint, either as to the service as a whole or as to any individual person(s) at a service site; and

c. The Human Rights Committee may make recommendations concerning necessary technical assistance or modification of the service to the Director and the appropriate Area Director.

(5) The Human Rights Committee shall review all complaints concerning the threat or use of restraint and, where appropriate, refer complaints for investigation in accordance with the requirements of 104 CMR 32.00: Investigation and Reporting Responsibilities.

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