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MASSACHUSETTS
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Standard or
Definition
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CMR 3.00: STANDARDS FOR THE LICENSURE OR
APPROVAL OF RESIDENTIAL PROGRAMS SERVING CHILDREN AND TEEN PARENTS
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Restraint
Definition
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Restraint. The use of any physical, mechanical or chemical means to temporarily
control behavior.
Physical restraint. A behavior management technique involving the
use of physical holding as a means of restricting a resident's freedom of
movement.
Physical restraint
includes holding a resident in a standing, seated or horizontal position.
Physical take down. The act of bringing a resident who is being
restrained to a sitting or horizontal position.
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Restraint
Exclusions
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Physical escort. Touching or holding of the hand, wrist, arm,
shoulder or back for the purpose of inducing an acting
out resident to walk to a safe location. A physical escort is not a physical
restraint.
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Chemical Restraint
Definition
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None.
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Seclusion
Definition
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None specified.
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Seclusion
Exclusions
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None specified.
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Criteria for
Restraint and Seclusion
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Each
licensee shall maintain a written statement defining rules, policies and
procedures for behavior management. This statement shall provide for and
include a description
of the safeguards for the emotional, physical and psychological well-being of
the population served. This statement shall include
measures for positive
responses to appropriate behavior and shall define and
explain the use of
behavior management procedures used in the facility
including, where
applicable:
1. level/point systems
of privileges, including procedures for the
resident's progress in
the program;
2. the type and range
of restrictions a staff member can authorize for
misbehavior of
residents;
3. the form of
physical restraint used, the behavioral interventions used
as alternatives to
restraint, including de-escalation techniques and
non-confrontational
approaches to angry or aggressive residents, and
controls on abuse of
such restraints;
4. the circumstances
under which the program would restrain a resident;
5. the name of the
restraint coordinator; and
6. the procedure for
regular review of restraint data by a restraint safety
committee.
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Unless the licensee obtains a variance prior to implementation, the use
of
any form
of restraint other than passive physical restraint is prohibited.
1.
Restraint of residents may be used only when:
a. the resident is demonstrating by
her/his actions that she/he is dangerous to her/him self or others;
b. no other intervention has been or is
likely to be effective in averting the danger.
2. No
resident shall be restrained for purposes of punishment or for the
convenience of others.
3. No
resident may be restrained solely for non-compliance with a program rule,
staff directive or expectation.
·
Any behavior management policy which results in a resident being
separated
from the group or program activities shall include, but not be
limited to
the following:
1.
guidelines for staff in the utilization of such procedures;
2. persons
responsible for implementing such procedures;
3. the
duration of such procedures including provisions for approval by
the chief
administrative person or his or her designee for a period longer
than 30
minutes.
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Monitoring
Requirements
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The
physical condition of a resident who is being restrained shall be constantly
monitored, as defined in 102 CMR 3.02.
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The
licensee shall immediately release a resident who exhibits any sign of
significant physical distress during restraint and shall immediately provide
the resident with any needed medical assistance.
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A
restrained resident shall be released at the first indication that it is safe
to do so.
·
It is
required that residents in seclusion be observable at all times and that
staff shall be in
close proximity at all times.
·
There must
be a procedure for staff to directly observe the resident at least every 15
minutes.
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Ordering and
Initiation
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Only staff trained in physical restraint shall participate in
restraining a resident.
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The administrative designee on the premises shall be notified
immediately whenever a physical restraint is initiated. The designee shall have
oversight responsibility of every physical restraint at the program.
·
After the first five minutes of each physical restraint, steps must be
initiated to contact the on-call administrative or clinical staff.
·
A licensee shall assure that the form of restraint used is the least
intrusive means necessary to protect the resident, other residents and staff.
Any restraint procedure which includes choke holds, headlocks, full nelsons,
half-nelsons, hog-tying or the use of pressure points to inflict pain is prohibited.
·
If a resident needs to be restrained for a period longer than 20
minutes, the approval of the chief administrative person or his or her
designee shall be obtained. Such approval shall be based upon the resident's
continued behavior justifying the need for continued restraint.
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In-person
Assessment
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None specified.
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Debriefing
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Each
resident who has been restrained shall be offered the opportunity to comment
in writing on the restraint as soon as possible within 24 hours of its
occurrence. Such comment shall be attached to the restraint incident report.
·
Following the release of a resident from a restraint, the program shall
implement its processing and follow-up procedures.
·
Any resident who has been restrained more than five times within any
seven day period must receive a review of her/his clinical and behavioral
needs by her/his assigned case manager or clinician within three working days
of the fifth restraint. If such review results in any change in services,
this must be documented in the resident's service plan, as required by 102
CMR 3.05(4) and (5).
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Family &
Guardian Notification
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None specified.
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Notification of
Rights and Restraint and Seclusion Policies and Procedures at admission
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The family will be
provided with a description and explanation of the program's method of
physical restraint, if applicable, and upon their request, a copy of the
program's prevention/restraint training curriculum.
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Training
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The
licensee shall provide orientation for all new employees to acquaint them
with the program's philosophy, organization, policies and services.
1. Each licensee shall
describe in writing the program's plan for staff orientation, which shall
include at a minimum, but not be limited to the characteristics of children
served; symptoms and behavioral signs of emotional disturbance; symptoms of
drug overdose, alcohol intoxication, or possible medical emergency; the
program's emergency and evacuation procedures, procedures for reporting
suspected incidents
of child abuse and
neglect, orientation in first aid and C.P.R., training in universal
precautions and infection control procedures, and the program's policies
regarding medication, runaway children, behavior management and restraint.
a. Each new employee (who
may work with residents) of a program which utilizes restraint shall receive
a minimum of sixteen (16) hours of training in the prevention and use of
restraint, which shall address the needs and behaviors of the population
served, relationship building, prevention of restraint, de-escalation
methods, avoiding power struggles, thresholds for restraints, the
physiological impact of restraint, monitoring physical signs of distress and
obtaining medical assistance, legal issues, positional asphyxia, escape and
evasion techniques, time limits, the process for obtaining approval for
continued restraints, procedures to address problematic restraints,
documentation, processing with children, and follow-up with staff, and
investigation of injuries and complaints.
b. Prevention/restraint
training shall include role-playing in de-escalation and demonstration of
proficiency with each hold taught, and written post-training tests.
2. No new employee
shall be solely responsible for children in care until s/he has received the
minimum orientation described above.
3. No employee shall
participate in a restraint until s/he has successfully completed the required
prevention/restraint training.
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The
licensee shall provide on-going staff training programs appropriate to the
size and nature of the program and staff involved. Each licensee shall
describe in writing the program's plan for staff training, including the
curriculum for prevention/restraint training and refresher training, if
applicable.
·
In any
program which utilizes physical restraint, the plan for staff training shall
include a minimum of 8 hours annual refresher training for each staff in
effective de-escalation and safe restraint methods, written post-training
tests, and regular review of restraints implemented.
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Documentation
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Incident
reports documenting the use of physical restraint must include at least the
following: the name of the resident; the names and positions of staff
involved in the restraint; the date and time of the restraint; the behavior
of the resident which prompted the restraint and a description of the
surrounding activities and environment at the time of the restraint; a
description of the efforts by staff to de-escalate the situation and the
alternatives to physical restraint attempted by staff; the justification for
the physical restraint; a detailed description of the actual physical
restraint, including starting and ending times; notation of what level of
restrictiveness the restraint reached (standing, sitting, floor);
documentation of the monitoring of the resident during the restraint;
documentation of approval for continuation of the restraint longer than 20
minutes, if applicable; documentation of processing and review of the
restraint with the resident following the restraint; documentation of any
injury to the resident and any medical care provided; signatures of all staff
involved in the restraint; and review of the incident report by the chief
administrative person or
his/her designee and
the restraint coordinator.
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The licensee shall document all restraints, including any required
administrative approval, and its processing and follow-up procedures in a
physical restraint incident report and keep such reports in the resident's
record.
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The licensee shall provide a means of documenting the use of seclusion
procedures if used for a period longer than 30 minutes including, at a
minimum, length of time, reasons for this intervention, who approved the
procedure and who directly observed the resident at least every 15 minutes.
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Reporting
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The licensee shall
submit, on a form provided by the Office, a quarterly report of all
restraints and injuries related to restraints in the program.
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Quality Improvement
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Restraint Coordinator. Licensee staff member responsible for
oversight of all matters related to restraint, including oversight and
documentation of training; ensuring that restraints are only employed when
necessary and that the restraint method taught is being used correctly; data
collection, analysis and reporting, and review, with the restraint safety
committee of restraint data and staff/resident safety information.
Restraint follow-up. Review by program management of each
restraint with involved staff as part of a feedback and quality assurance
process.
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