New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21
Subchapter 3 - EMERGENCY SAFETY INTERVENTIONS
Section 10:75-3.11 - Evaluation after the emergency safety intervention

Universal Citation: NJ Admin Code 10:75-3.11

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Immediately after the drug or mechanical restraint or seclusion is over, for in-State facilities, a physician, an advance nurse practitioner, a registered nurse or a physician's assistant who is trained in the use of emergency safety interventions shall evaluate the physical and mental condition of the resident. Staff may use on-call staff to perform either or both parts of the evaluation as long as they assure the evaluation is completed timely. Out-of-State facilities shall follow their state Medicaid program requirements for who shall perform this evaluation.

(b) Immediately after the personal restraint is over, for in-State facilities, licensed staff who are not precluded from making an evaluation of the well-being of the child, and who are trained in the use of emergency safety interventions, shall evaluate the well-being of the resident. Staff may use more than one staff member to perform both parts of the evaluation as long as they assure the evaluation is completed timely. Out-of-State facilities shall follow their state Medicaid program requirements for who shall perform this evaluation.

(c) For all emergency safety interventions, staff shall document the intervention no later than the end of the shift in which the emergency safety intervention ended. Documentation shall include, at a minimum:

1. The name of the physician/practitioner who gave the order;

2. The date and time that the order was given, including the name and title of who received the order;

3. The type of intervention order, including the length of time authorized for the use of the intervention;

4. The actual time of the initiation and termination of the intervention;

5. The actual time and results of all evaluations performed during or after the intervention;

6. The emergency safety situation that required the use of the intervention; and

7. The name, title and credentials of all staff involved in the intervention.

(d) If the practitioner ordering the intervention is not the resident's treatment team physician, the ordering practitioner, or the professional receiving the order, shall consult with the resident's treatment team physician as soon as possible to advise the physician of the intervention. Documentation of the date and time the treatment team physician was consulted shall be included in the resident's record.

(e) All entries into the record shall be legible and the person entering the information shall print and sign their name in ink, including their title and the date that the entry was made.

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