Current through Supplement No. 394, October, 2024
A facility shall have written policies and procedures
regarding implementation of special treatment procedures. Special treatment
procedures must be therapeutic and meaningful interventions and may not be used
for punishment, for the convenience of employees, or as substitute for
therapeutic programming. Upon admission, the facility shall inform the child
and the person who may lawfully act on behalf of the child of the facility
policy on restraint and seclusion procedures during an emergency safety
situation. The facility shall provide education to the children, providing each
child the opportunity to express the child's opinion and educating the child on
alternative behavior choices to avoid the use of special treatment procedures.
Alternatives to behaviors must be documented in each child's individual
person-centered treatment plan. The health, safety, and well-being of children
receiving care and treatment in the facility must be properly safeguarded. A
physician shall review the use of special treatment procedures.
1. Timeout. Employees shall supervise the use
of timeout procedures at all times, and shall document the use of timeout
procedures in the child's file. The use of the resident's bedroom for timeout
is prohibited.
2. Physical escort.
Employees shall supervise the use of physical escort procedures at all times
and shall document the use of physical escort in the child's file.
3. Physical restraints.
a. Physical restraints must be ordered by a
psychiatrist or other physician, a licensed psychologist, a licensed clinical
social worker, or a nurse who holds advanced licensure in psychiatric nursing.
Staff authorized to order physical restraint must be trained in the use of
emergency interventions. A psychiatrist or other physician, a licensed
psychologist, a licensed clinical social worker, or a nurse who holds advanced
licensure in psychiatric nursing must review and sign the order within
forty-eight hours after the ordered physical restraint. Physical restraints may
be imposed only in emergency circumstances and must be used with extreme
caution to ensure the immediate physical safety of the child, an employee, or
others after all other less intrusive alternatives have failed or have been
deemed inappropriate;
b. All
physical restraints must be applied by employees who are certified in the use
of restraints and emergency safety interventions; and
c. The facility shall have established
protocols that require:
(1) Entries made in
the child's file as to the date, time, employee involved, reasons for the use
of, and the extent to which physical restraints were used, and which identify
less restrictive measures attempted;
(2) Notification within twelve hours of the
individual who lawfully may act on behalf of the child; and
(3) Face-to-face assessment of children in
physical restraint completed by a psychiatrist or other physician, a licensed
psychologist, a licensed clinical social worker, a nurse who holds advanced
licensure in psychiatric nursing, or other licensed health care professional or
practitioner who is trained in the use of safety, emergency interventions. The
face-to-face assessment must be documented in the child's case file and include
assessing the mental and physical well-being of the child. The face-to-face
assessment must be completed as soon as possible, and no later than one hour
after the initiation of physical restraint or seclusion.
4. Seclusion. Seclusion must be
ordered by a psychiatrist or other physician, a licensed psychologist, a
licensed clinical social worker, or a nurse who holds advanced licensure in
psychiatric nursing. Staff authorized to order seclusion must be trained in the
use of emergency interventions. A psychiatrist or other physician, a licensed
psychologist, a licensed clinical social worker, or a nurse who holds advanced
licensure in psychiatric nursing must review and sign the order within
forty-eight hours after the ordered seclusion. Seclusion may be imposed only in
emergency circumstances after all other less intrusive alternatives have failed
or have been deemed inappropriate. Seclusion is to be used with extreme
caution, and only to ensure the immediate physical safety of the child, an
employee, or others. A child's bedroom may not be used for seclusion. If
seclusion is indicated, the facility shall ensure that:
a. The proximity of the employee allows for
visual and auditory contact with the child at all times;
b. Employees conduct assessments of the child
every fifteen minutes and document the assessments in the child's case
file;
c. The seclusion room is not
locked, or is equipped with a lock that only operates with an employee present
such as a push-button lock that only remains locked while it is being
pushed;
d. All nontherapeutic
objects are removed from the area in which the seclusion occurs;
e. All fixtures within the room are
tamperproof, with switches located outside the room;
f. Smoke-monitoring or fire-monitoring
devices are an inherent part of the seclusion room;
g. Security mattresses used are made of
fire-resistant material;
h. The
room is properly ventilated;
i.
Notification of the individual who lawfully may act on behalf of the child is
made within twelve hours of a seclusion and is documented in the child's case
file;
j. A child under special
treatment procedures is provided a similar diet that other children in the
facility are receiving;
k. No child
remains in seclusion:
(1) For more than four
hours in a twenty-four-hour period; and
(2) Without physician approval;
l. Seclusion is limited to the
maximum time frame per episode for fifteen minutes for children aged nine and
younger and one hour for children aged ten and older; and
m. Face-to-face assessment of children in
seclusion is completed by a psychiatrist or other physician, licensed
psychologist, a licensed clinical social worker, a nurse who holds advanced
licensure in psychiatric nursing, or other licensed health care professional or
practitioner who is trained in the use of safety, emergency interventions. The
face-to-face assessment must be documented in the child's case file and include
assessing the mental and physical well-being of the child. The face-to-face
assessment must occur no later than one hour after the initiation of
seclusion.
5. Within
twenty-four hours of each use of seclusion or physical restraint, the facility
shall conduct a face-to-face discussion which includes the child and all
employees involved in the emergency intervention, except when the involvement
of a particular employee may jeopardize the wellbeing of the child, and which:
a. Evaluates and documents in the child's
case file the well-being of the child served and identifies the need for
counseling or other therapeutic services related to the incident;
b. Identifies antecedent behaviors and
modifies the child's individual person-centered treatment plan as appropriate;
and
c. Analyzes the incident and
identifies needed changes to policy and procedures, employee training, and
strategies that could have been used by an employee, by the child, or by others
which could prevent the future use of seclusion or physical
restraint.
6. Within
twenty-four hours after the use of physical restraint or seclusion, all
employees involved in the emergency safety intervention, and appropriate
supervisory and administrative employees, shall conduct a debriefing session
that includes, at a minimum a review and discussion of:
a. Precipitating factors to the emergency
situation;
b. Alternative
techniques that might have prevented the use of physical restraint or
seclusion;
c. The procedures, if
any, that employees are to implement to prevent any recurrence of the use of
physical restraint or seclusion; and
d. The outcomes of the intervention,
including any injuries that may have resulted from the use of the physical
restraint or seclusion.
7. Employees shall document in the child's
record both the face-to-face discussion and debriefing sessions identified in
subsections 5 and 6 and the names of employees involved, employees excused, and
any changes to the child's treatment plan as a result of the face-to-face
discussion and debriefing. The facility also shall document that the person who
may lawfully act on behalf of the child was notified.
8. Special treatment procedure training. Each
facility must have policies and procedures regarding annual training in the use
of all special treatment procedures listed in this section, which comply with
the standards set forth by the facility's accrediting body.
General Authority: NDCC 25-03.2-10
Law Implemented: NDCC 50-11-03,
50-11-03.2
