10A ncac 28D .0206       PROCEDURES: SECLUSION, physical RESTRAINTS, OR ISOLATION TIME OUT

(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.

 

History Note:        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.