SECTION 550.207. Protective Devices and Restraints

(a) Protective Devices. A center must ensure that a protective device is used only as ordered by a minor's physician, as agreed to by an adult minor or a minor's parent, and in accordance with the minor's plan of care.

(1) A center may use a protective device only in the following circumstances:

(A) as part of a therapeutic regimen of basic services for a minor's physical health and development;

(B) during medical, nursing, diagnostic, and dental procedures as prescribed by a physician's order and to protect the health and safety of a minor; or

(C) in a medical emergency to protect the health and safety of a minor.

(2) A center must adopt and enforce written policies and procedures requiring a protective device to be used as described in this subsection and in accordance with a minor's plan of care.

(3) A center must not implement a physician's order for the use of a protective device on a pro re nata (PRN) or as-needed basis.

(4) A center must ensure a physician's order is obtained before using a protective device at the center. The physician's order must include:

(A) the circumstances under which a protective device may be used at the center;

(B) instructions on how long a protective device may be used at the center; and

(C) any individualized, less restrictive interventions described in the minor's plan of care that must be used before using a protective device.

(5) A center must ensure that in implementing a physician's order for a protective device that an RN, with input from an adult minor, a minor's parent, and the IDT:

(A) conducts an assessment of a minor's current and ongoing need for a protective device at a center;

(B) reviews the physician's order for a protective device, as described in paragraph (4) of this subsection; and

(C) obtains and documents in a minor's medical record the written consent of an adult minor or a minor's parent to use a protective device at the center.

(6) Before using a protective device for the first time with a minor, the center must ensure an RN provides oral and written notification to the adult minor or the minor's parent of the right at any time to withdraw consent and discontinue use of a protective device at the center.

(7) The center must ensure that a staff member who will apply a protective device has been properly trained in the use of a protective device, as ordered in the minor's plan of care, in accordance with this subsection, and in accordance with §15.415(b)(8)(F) of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training).

(8) If a protective device is used for a minor, the center must ensure:

(A) the minor is assessed by an RN, in accordance with the physician's order but no less than once every hour to determine if the protective device must be repositioned or discontinued;

(B) except for sedation, the protective device is removed to conduct the RN assessment described in subparagraph (A) of this paragraph and removed more frequently as determined necessary by the RN's assessment;

(C) center staff replaces the protective device, if necessary, after the assessment, in accordance with the physician's order;

(D) a minor's physician is notified immediately if an assessment determines a change in the minor's condition or a negative reaction to the protective device has occurred, including notification of:

(i) the minor's psychosocial condition;

(ii) the minor's reaction to the protective device;

(iii) the minor's medical condition; and

(iv) the need to continue or discontinue the use of the protective device;

(E) the type and frequency of use of the protective device is documented in the minor's medical record;

(F) the effects of a protective device on the minor's health and welfare are evaluated and documented in the medical record; and

(G) an RN, an adult minor, a minor's parent, and the IDT, at least every 180 days, or as the minor's needs change, review, with input and direction from the minor's prescribing physician, the use of a protective device to determine its effectiveness and the need to continue the use of the protective device.

(b) Restraints. A center may use a restraint only in a behavioral emergency when the immediate health and safety of the minor or another minor are at risk. A center must not use a chemical or mechanical restraint. A center may use only the following restraints:

(1) The center must adopt and enforce a written policy and procedures regarding the use of restraints in a behavioral emergency, including whether a center is a restraint-free environment.

(2) A center must ensure that the use of a restraint at a center must not be in a manner that:

(A) obstructs a minor's airway, including the placement of anything in, on, or over the minor's mouth or nose;

(B) impairs the minor's breathing by putting pressure on the minor's torso;

(C) interferes with the minor's ability to communicate;

(D) extends muscle groups away from each other;

(E) uses hyperextension of joints; or

(F) uses pressure points or pain.

(3) A center must ensure that a restraint is not used for:

(A) controlling a minor's behavior in a non-emergency;

(B) negative discipline as described in §15.206 of this division (relating to Person-Centered Direction and Guidance);

(C) convenience;

(D) coercion or retaliation; or

(E) as part of a behavior component of a minor's psychosocial program.

(4) A center must not implement a physician's order for the use of a restraint on a pro re nata (PRN) or as-needed basis.

(5) A center must ensure that a staff member whose job responsibilities will include the use or application of a restraint during a behavioral emergency has been properly trained in the use of a restraint for minors served at the center, in accordance with this section, and in accordance with §15.415(b)(8)(G) of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training).

(6) If a center restrains a minor due to a behavioral emergency, the center must ensure:

(A) all less restrictive options available are exhausted before using a restraint;

(B) the restraint is limited to the use of such reasonable force as is necessary to address the emergency;

(C) the restraint is discontinued immediately at the point when the emergency no longer exists but no more than 15 minutes after the restraint was initiated;

(D) the restraint is implemented in such a way as to protect the health and safety of the minor and others;

(E) immediately after the restraint is discontinued, the minor is assessed by an RN;

(F) immediately following an RN assessment, medical attention is provided for the minor if determined necessary by the RN assessment;

(G) within three days after the use of the restraint, an assessment is conducted by an RN as described in §15.504 of this chapter (relating to Psychosocial Treatment and Services) to determine if the development and implementation of a psychosocial treatment and services program is needed for the minor to address the minor's behavior and reduce the occurrence of future behavioral emergencies; and

(H) within three days after the use of the restraint, an RN reviews and updates a minor's plan of care and psychosocial treatment and services program as determined appropriate.

(7) If a center restrains a minor due to a behavioral emergency, the center must ensure the following documentation and notifications occur:

(A) immediately after the restraint is discontinued, information about the restraint is documented, including:

(i) the name of the individual who administered the restraint;

(ii) the date and time the restraint began and ended;

(iii) the location of the restraint;

(iv) the nature of the restraint;

(v) a description of the setting and activity in which the minor was engaged immediately preceding the use of the restraint;

(vi) the behavior that prompted the restraint;

(vii) the efforts made to de-escalate the situation and the less restrictive alternatives attempted before the restraint; and

(viii) the minor's condition after the restraint was discontinued;

(B) within 24 hours after the use of the restraint, written documentation regarding the use of the restraint and the RN assessment conducted immediately after the use of the restraint is included in a minor's medical record;

(C) documentation of nursing director and administrator oral and written notifications as described in subparagraphs (E) and (I) of this paragraph, including nursing director and administrator signatures acknowledging receipt of notifications must be included in the minor's medical record;

(D) documentation of parent oral and written notifications as described in subparagraphs (F) and (J) of this paragraph, including a parent signature acknowledging receipt of notifications must be included in the minor's medical record;

(E) immediately after the restraint is used, the administrator and director of nursing are notified orally that the restraint occurred;

(F) on the day the restraint is used, the minor's parent is notified orally that the restraint occurred;

(G) on the day the restraint is used, the center's staff responsible for psychosocial treatment and services is notified orally that the restraint occurred;

(H) immediately after the RN assessment is conducted in accordance with paragraph (6)(E) of this subsection, if the assessment determines a change in the minor's condition or a negative reaction to the restraint has occurred, the minor's physician is notified of the restraint and the minor's condition, including:

(i) the minor's medical condition;

(ii) the minor's reaction to the restraint; and

(iii) the minor's psychosocial condition;

(I) within one hour after the use of the restraint, the administrator and director of nursing are notified in writing of the restraint, including the information in subparagraph (A) of this paragraph; and

(J) within one day after the use of the restraint, the minor's parent is notified in writing, in a language and format the parent understands, of the restraint, including the information in subparagraph (A) of this paragraph;

(8) The IDT must review, on an annual basis or more frequently as needed, all behavioral emergencies that occurred at the center during the time period being reviewed to determine the appropriateness of the center's response and to identify strategies for reducing behavioral emergencies at the center.

(9) A center must maintain documentation of compliance with this section.

Source Note: The provisions of this §550.207 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875