SECTION 749.2305. When must a caregiver document the use of an emergency behavior intervention, and what must the documentation include?

(a) As soon as possible, but no later than 24 hours after the initiation of the intervention, the caregiver must document in the child's record the following information:

(1) The child's name;

(2) A description and assessment of the circumstances and specific behaviors that caused the basis for the emergency behavior intervention;

(3) The de-escalation attempted before and during the use of the emergency behavior intervention and the child's reaction to those strategies;

(4) The specific emergency behavior intervention administered;

(5) The date and time the intervention was administered;

(6) The length of time the child was restrained;

(7) The name of the caregiver(s) that participated in the incident that led to the intervention, and who administered the intervention;

(8) The name of the person(s) who observed the child;

(9) The names of any witnesses to the emergency behavior intervention, including child witnesses in the home;

(10) All attempts to explain to the child what behaviors were necessary for release from the intervention;

(11) The child's condition following the use of the medication or release from the intervention, including any injury the child sustained as a result of the intervention or any adverse effects caused by the use of the intervention. If the child received medical assistance or treatment, the caregiver must document the name of the person(s) who provided medical assistance or treatment; and

(12) The actions the caregiver(s) took to facilitate the child's return to normal activities following the end of the intervention.

(b) The child placement staff must document their review of the use of the emergency behavior intervention within 72 hours of the incident.

(c) If personal restraint is used, documentation must also include the specific restraint techniques used, including a prone or supine restraint used as a transitional hold.

(d) If emergency medication is used, documentation must also include the specific medication used and the dosage administered to the child.

(e) This rule does not apply to short personal restraints.

Source Note: The provisions of this §749.2305 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909