Current through Register Vol. 39, No. 6, September 16, 2024
(a) This Rule delineates the procedures to be
followed for use of seclusion, physical restraint or isolation time-out in
addition to the procedures specified in Rule .0203 of this Section.
(b) This Rule governs the use of physical or
behavioral interventions which are used to terminate a behavior or action in
which a client is in imminent danger of injury to self or other persons or when
property damage is occurring that poses imminent risk of danger, of injury or
harm to self or others, or which are used as a measure of therapeutic
treatment. Such interventions include seclusion, physical restraint and
isolation time-out.
(c) If
determined to be acceptable for use within the state facility, the state
facility director shall establish written policies and procedures that govern
the use of seclusion, physical restraint or isolation time-out which shall
include the following:
(1) techniques for
seclusion, physical restraint or isolation time-out;
(2) provision for required debriefing for
emergency use of seclusion, physical restraint or isolation time-out;
(3) provision, to both new clinical and
habilitation staff as part of in-service training, and as a condition of
continued employment, for those authorized to use or apply intrusive
interventions which shall include, but not be limited to:
(A) competency-based training and periodic
reviews on the use of seclusion, physical restraint or isolation time-out;
and
(B) skills for less intrusive
interventions specified in Rules .0203 and .0204 of this Section;
(4) process for identifying,
training and assessing the competence of state facility employees who are
authorized to use such interventions;
(5) provisions that a responsible
professional shall:
(A) meet with the client
and review the use of the intervention as soon as possible but at least within
one hour after the initiation of its use;
(B) verify the inadequacy of positive
alternatives and less restrictive intervention techniques;
(C) document in the client record evidence of
approval or disapproval of continued use; and
(D) inspect to ensure that any devices to be
used are in good repair and free of tears and protrusions;
(6) procedures for documenting the
intervention which occurred to include, but not be limited to:
(A) consideration that was given to the
physical and psychological well-being of the client prior to the use of the
restrictive intervention;
(B) the
rationale for the use of the intervention which addresses attempts at and
inadequacy of positive alternatives and less restrictive intervention
techniques; this shall contain a description of the specific behaviors
justifying the use of seclusion, physical restraint or isolation
time-out;
(C) notation of the
frequency, intensity and duration of the behavior and any precipitating
circumstances contributing to the onset of the behavior;
(D) description of the intervention and the
date, time and duration of its use;
(E) estimated amount of additional time
needed in seclusion, physical restraint or isolation time-out;
(F) signature and title of the state facility
employee responsible for the use of the intervention;
(G) the time the responsible professional met
with the client; and
(H)
description of the debriefing and planning with the client and the legally
responsible person, if applicable, as specified in Subparagraph (c)(2) of this
Rule, or Subpart (b)(6)(A)(xi) of Rule .0203 of this Section, to eliminate or
reduce the probability of the future use of restrictive interventions;
and
(7) procedures for
the notification of others to include:
(A)
those to be notified as soon as possible but no more than one working day after
the behavior has been controlled to include:
(i) the treatment/habilitation team, or its
designee, after each use of the intervention;
(ii) a designee of the State Facility
Director; and
(iii) the internal
client advocate, in accordance with the provisions of
G.S.
122C-53(g); and
(B) immediate notification of the
legally responsible person of a minor client or an incompetent adult client
unless she/he has requested not to be notified.
(d) Seclusion, physical restraint and
isolation time-out shall not be employed as coercion, punishment or retaliation
or for the convenience of staff or due to inadequate staffing or be used in a
manner that causes harm or pain to the client. Care shall be taken to minimize
any physical or mental discomfort in the use of these interventions.
(e) Whenever a client is in seclusion,
physical restraint or isolation time-out, the client's rights, as specified in
G.S.
122C-62, are restricted. The documentation
requirements in this Rule shall satisfy the requirements specified in
G.S.
122C-62(e) for restriction
of rights.
(f) Whenever seclusion,
physical restraint or isolation time-out is used more than three times in a
calendar month:
(1) a pattern of behavior has
developed and future emergencies can be reasonably predicted;
(2) dangerous behavior can no longer be
considered unanticipated; and
(3)
emergency procedures shall be addressed as a planned intervention in the
treatment/habilitation plan.
(g) In addition to the requirements in this
Rule, additional safeguards as specified in Rule .0208 of this Section shall be
initiated whenever:
(1) a client exceeds
spending 40 hours in emergency seclusion, physical restraint or isolation
timeout in a calendar month; or one episode in which the original order is
renewed for up to a total of 24 hours in accordance with the limits specified
in Subparagraph (l)(8) of this Rule; or
(2) seclusion, physical restraint or
isolation time-out is:
(A) used as a measure
of therapeutic treatment as specified in
G.S.
122C-60; and
(B) limited to specific planned behavioral
interventions designed for the extinction of dangerous, aggressive or
undesirable behaviors.
(h) The written approval of the State
Facility Director or designee shall be required when the original order for
seclusion, physical restraint or isolation time-out is renewed for up to a
total of 24 hours in accordance with the limits specified in Subparagraph
(l)(8) of this Rule.
(i) Standing
orders or as needed (PRN) orders shall not be used to authorize the use of
seclusion, physical restraint or isolation time-out.
(j) A state facility employee shall remove
the client from seclusion, physical restraint or isolation time-out and seek
medical attention immediately if monitoring of the physical and psychological
well-being of the client indicates there is a risk to health or
safety.
(k) The client shall be
removed from seclusion, physical restraint or isolation time-out when the
client no longer demonstrates the behavior which precipitated the seclusion,
physical restraint or isolation time-out; however, if the client is unable to
gain self-control within the time frame specified in the authorization, a new
authorization shall be obtained.
(l) Whenever seclusion, physical restraint or
isolation time-out are used on an emergency basis prior to inclusion in the
treatment/ habilitation plan, the following procedures shall be followed:
(1) A state facility employee authorized to
administer emergency interventions may employ such procedures for up to 15
minutes without further authorization.
(2) A qualified professional may authorize
the continued use of seclusion, physical restraint or isolation time-out for up
to one hour from the initial employment of the intervention if the qualified
professional:
(A) has experience and training
in the use of seclusion, physical restraint or isolation time-out;
and
(B) has been approved to employ
and authorize such interventions.
(3) If a qualified professional is not
immediately available to conduct a face-to-face assessment of the client, but
after discussion with the state facility employee, the qualified professional
concurs that the intervention is justified for longer than 15 minutes, then the
qualified professional:
(A) may verbally
authorize the continuation of the intervention for up to one hour;
(B) shall meet with and assess the client
within one hour after authorizing the continued use of the intervention;
and
(C) shall immediately consult
with the professional responsible for the client's treatment/habilitation plan,
if the intervention needs to be continued for longer than one hour.
(4) The responsible professional
shall authorize the continued use of seclusion, physical restraint or isolation
time-out for periods over one hour.
(5) If the responsible professional is not
immediately available to conduct a clinical assessment of the client but, after
consideration of the physical and psychological well-being of the client and
discussion with the qualified professional, concurs that the intervention is
justified for longer than one hour the responsible professional may verbally
authorize the continuation of the intervention until an on-site assessment of
the client can be made. However, if such authorization cannot be obtained, the
intervention shall be discontinued.
(6) If the responsible professional and the
qualified professional are the same person, the documentation requirements of
this Rule may be done at the time of the documentation required by Subparagraph
.0206(d)(5) of this Section.
(7)
The responsible professional, or if the responsible professional is
unavailable, the on-service or covering professional, shall meet with and
assess the client within three hours after the client is first placed in
seclusion, physical restraint or isolation time-out, and document:
(A) the reasons for continuing seclusion,
physical restraint or isolation time-out; and
(B) the client's response to the
intervention. In addition, the responsible professional shall provide an
evaluation of the episode and propose recommendations regarding specific means
for preventing future episodes. Clients who have been placed in seclusion,
physical restraint or isolation time-out and released in less than three hours
shall be examined by the responsible professional who authorized the
intervention no later than 24 hours after the episode.
(8) Each written order for physical
restraint, seclusion or isolation timeout is limited to four hours for adult
clients; two hours for children and adolescent clients ages nine to 17; or one
hour for clients under the age of nine. The original order shall only be
renewed in accordance with these limits for up to a total of 24
hours.
(9) Each incident shall be
reviewed by the treatment team, which shall include possible alternative
actions and specific means for preventing future episodes.
(m) While the client is in seclusion,
physical restraint or isolation time-out, the following precautions shall be
followed:
(1) Whenever a client is in
seclusion:
(A) periodic observation of the
client shall occur at least every 15 minutes to assure the safety of the
client. Observation shall include direct line of sight or the use of video
surveillance that ensures that the client is within the view of the state
facility employee observing the client;
(B) attention shall be paid to the provision
of regular meals, bathing and the use of the toilet; and
(C) such observation and attention shall be
documented in the client record.
(2) Whenever a client is in physical
restraint, the facility shall provide:
(A)
the degree of observation needed to assure the safety of the client placed in
physical restraint. The degree of observation needed is determined at the time
of application of the physical restraint after consideration of the following:
(i) the type of physical restraint
used;
(ii) the individual client's
situation, including physical and psychological well-being; and
(iii) the existence of any specific
manufacturer's warning concerning the safe use of a particular product.
Observation shall include direct line of sight or the use
of video surveillance that ensures that the client is within the view of the
state facility employee observing the client. In no instance shall observation
be less frequent than at 15-minute intervals.
(B) attention to the provision of regular
meals, bathing and the use of the toilet; and
(C) documentation of the above observation
and attention in the client record.
(3) Whenever a client is in isolation
time-out there shall be:
(A) a state facility
employee in attendance with no other immediate responsibility than to monitor
the client who is placed in isolation time-out;
(B) continuous observation and verbal
interaction with the client when necessary to prevent tension from escalating;
and
(C) documentation of such
observation and verbal interaction in the client record.
(n) After a restrictive
intervention is utilized, staff shall conduct debriefing and planning with the
client and the legally responsible person, if applicable, as specified in
Subparagraph (d)(2) of this Rule, or Subpart (b)(6)(A)(xi) of Rule .0203 of
this Section, to eliminate or reduce the probability of the future use of
restrictive interventions. Debriefing and planning shall be conducted as
appropriate to the level of cognitive functioning of the client.
(o) Reviews and reports on the use of
seclusion, physical restraint or isolation time-out shall be conducted as
follows:
(1) the State Facility Director or
designee shall review all uses of seclusion, physical restraint or isolation
time-out and investigate unusual patterns of utilization to determine whether
such patterns are unwarranted. At least quarterly, the State Facility Director
or designee shall review all uses of seclusion and physical restraint to
monitor effectiveness, identify trends and take corrective action where
necessary.
(2) each State Facility
Director shall maintain a log which includes the following information on each
use of seclusion, physical restraint or isolation time-out:
(A) name of the client;
(B) name of the responsible
professional;
(C) date of each
intervention;
(D) time of each
intervention;
(E) duration of each
intervention;
(F) name of the state
facility employee who implemented the restrictive intervention;
(G) date and time of the debriefing and
planning conducted with the client and the legally responsible person if
applicable and staff to eliminate or reduce the probability of the future use
of restrictive interventions; and
(H) negative effects of the restrictive
intervention, if any, on the physical and psychological well-being of the
client.
(p)
The facility shall collect and analyze data on the use of seclusion and
physical restraint. The data collected and analyzed shall reflect for each
incident:
(1) the type of procedure used and
length of time employed;
(2)
alternatives considered or employed; and
(3) the effectiveness of the procedure or
alternative employed.
The facility shall analyze the data on at least a quarterly
basis to monitor effectiveness, determine trends and take corrective action
where necessary. The facility shall make the data available to the Secretary of
the Department of Health and Human Services upon request.
(q) Nothing in this Rule shall be
interpreted to prohibit the use of voluntary seclusion, physical restraint or
isolation time-out at the client's request; however, the procedures in
Paragraphs (a) through (p) of this Rule shall apply.
Authority
G.S.
122C-51;
122C-53;
122C-57;
122C-60;
122C-62;
131E-67;
143B-147;
Eff.
October 1, 1984;
Amended Eff. July 1, 1994; January 4, 1994;
November 1, 1993; April 1, 1990;
Temporary Amendment Eff. January
1, 2001;
Temporary Amendment Expired October 13, 2001;
Amended Eff. April 1, 2003;
Pursuant to
G.S.
150B-21.3A, rule is necessary without
substantive public interest Eff. May 1, 2018.
