Continuous Quality Improvement
Restraint OF cLIENTS pOLICY 19-21
The use of restraint is a non-therapeutic physical intervention that carries the risk of trauma and/or physical injury to both clients and staff, and shall only be used to prevent immediate or imminent injury to the individual or to others.
Physical restraint is not an intervention for the convenience of staff, or to coerce clients, or to enforce compliance, or to discipline clients and is only to be used to prevent immediate or imminent injury to the individual or to others.
The application of physical restraint for each child must always take into
consideration a child specific risk assessment including factors such as, but not limited to, developmental level, chronological age, gender, weight, existing health conditions, medications, and any history of victimization.
Legal Reference: CGS §46a-150-§46a-154
Individual Program Policy -
Each program or facility that uses physical restraint must address the following in policy:
- a strong purpose statement
- de-escalation procedure
- definitions and conditions for use
- risk assessments
- attention to monitoring and assessment
- staff training
- data collection and dissemination.
Required Elements of Restraint Policies and Procedures -
A program or facility's statement of purpose shall include the following elements:
- Physical restraint shall be used only as a response to emergency situations and after all other less restrictive strategies have been exhausted, except in those cases where the emergency is so severe that physical restraint is required to prevent immediate or imminent injury to the individual or to others.
- It must be stressed that the act of being restrained may be traumatic to the client and staff involved, as well as to other clients exposed to the restraint, and that all efforts must be made to preserve the autonomy and protect the dignity of the individual being restrained.
- Physical restraint is considered to be an emergency safety intervention and is not considered to be treatment.
- The use of physical restraint shall take into consideration a risk assessment which includes factors such as developmental level, chronological age, gender, weight, existing health conditions, medications used, and any history of victimization.
Reporting of Suicide Attempts and Serious Injuries During Restraints -
All suicide attempts and serious injuries during restraint shall be reported by DCF facilities to the DCF Risk Management Unit in the Bureau of Continuous Quality Improvement. Reports received from Riverview Hospital and any other subacute facility will be forwarded, by the Risk Management Unit, to the Department of Social Services and the Office of Protection and Advocacy as required by CMS regulation and to the Department of Public Health as required by law. Reports received from facilities not designated as psychiatric residential treatment facilities (PRTF) or hospitals (acute care facilities) will only be forwarded, by the Risk Management Unit to the Office of Protection and Advocacy where required by state statute."
Definitions and Conditions of Use -
A program or facility's policy shall include an explanation of issues, terms or situations that may be indigenous to each program as well as the following definitions and conditions of use:
- "Physical restraint" is defined as any mechanical, chemical or personal restriction that results in immobilization of a person or reduces free movement of a person's arms, legs or head.
- "Escort" is defined as a situation in which a staff member provides physical prompts that serve to guide but not control the client.
- "Serious injury" is defined as any significant impairment of the physical condition of the person at risk as determined by qualified medical personnel. This includes, but is not limited to, burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else.
- Physical restraint is an emergency intervention utilizing the least amount of force necessary to prevent immediate or imminent injury to the client or others.
- Physical restraint does not include the minimum contact necessary to safely escort a person from one area to another.
- The use of physical restraint with a specific child may be determined to be necessary and appropriate as a result of a risk assessment conducted on an individual basis for each client and documented in the treatment plan or plan of care.
- Physical restraint is NOT to be used to coerce, discipline or punish clients.
- Physical restraint is NOT to be used for the convenience of staff or to enforce compliance.
- Physical restraint does not include the reasonable intervention of program or facility staff in the event of an attempted AWOL. Program staff may make reasonable efforts, e.g., verbal de-escalation, pursuit of the client, maintenance of ongoing observation and attempted escort.
- A locked facility is a facility that uses mechanical or electronic locking devices to limit access and egress. The use of time delay locks, auditory or visual alert devices, etc. are not considered to define a locked facility.
- If a child or youth requires placement in a locked facility elopement (AWOL) of that individual from that facility may pose an imminent or immediate risk of harm to self or others, thus justifying the use of physical restraint, if necessary.
- Physical restraint may not be used to prevent a child or youth from inflicting property damage unless the behavior or potential damage creates a situation which would result in immediate or imminent injury to the child or others.
- Physical restraint may only be used by individuals who have been trained in established methods of crisis intervention.
Risk Assessment -
A risk assessment shall be done for each client that addresses: the likelihood of imminent or immediate injury to the client in the course of a restraint; the risk of a dangerous or untoward event occurring if the client should elope; and the risk that physical intervention might do harm based on vulnerabilities of cognition, previous trauma history or medical fragility.
- Risk assessments must be conducted as close to admission as possible in order to determine if an individual is likely to require physical restraint.
- The risk assessment shall be reviewed on an ongoing basis as conditions change.
- The risk assessment shall include attention to: history of trauma, victimization, obesity or abdominal girth, respiratory or cardiac problems, age, cognitive developmental level, medication, physical problems/physical disabilities, psychiatric history and medical history.
Crisis Management Plan -
In addition to the risk assessment, a crisis management plan shall be developed for each client. This plan shall articulate strategies for avoiding the use of physical restraints and shall include preferred or prohibited techniques in the event that physical restraint is necessary. The crisis management plan shall be reviewed when the treatment plan is reviewed.
- The plan developed for each client shall articulate strategies for avoiding restraints.
- The plan developed for each client shall articulate preferred or prohibited techniques.
- The plan which results from the risk assessment shall be revised as necessary when the treatment plan is reviewed.
Monitoring and Assessment -
All uses of physical restraint shall be monitored and the client shall be assessed to ensure safety.
- In the course of physical restraint the situation must be constantly monitored by staff.
- Regular and periodic assessment is necessary to identify medical problems, indications of stress injury and to identify the appropriate time for release.
- Monitoring must be conducted by an individual trained in the use of emergency safety interventions, cardiopulmonary resuscitation and first aid.
- Within 15 minutes of the initiation of the restraint, an individual trained in emergency safety interventions, CPR and first aid shall conduct a face-to-face assessment of the physical and psychological well being of the child. Successive assessments shall continue at least every 15 minutes until the restraint is completed. A final assessment shall be conducted immediately following the completion of the restraint.
- Every assessment shall include, but not be limited to:
- Signs of physical injury e.g., bleeding, swelling, physical distress, difficulty breathing.
- The client's behavior and emotional condition.
- The appropriateness of the intervention.
- Any complications resulting from the intervention.
- Continuing need for the emergency intervention/restraint.
· Each program shall maintain and implement standards to ensure the individual comfort of the client e.g. bathroom breaks, covering areas of the body exposed during a restraint.
A debriefing session shall occur after every occasion of restraint with both the client and the staff involved.
- The purpose of the debriefing is to identify antecedent events and behavioral triggers as well as to develop strategies on how to prevent reoccurrences.
- Debriefings shall occur with the staff involved and with the client, though not necessarily at the same meeting.
- Debriefing shall be held within 24 hours after the use of the restraint.
- Other staff and the client's parents or legal guardian may participate in the discussion when it is deemed appropriate by the facility.
- The debriefing shall provide the staff and the client the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and attempts shall be made to identify strategies that could prevent further use of restraints.
- Debriefing sessions shall include:
- A description of the emergency situation including the events that may have contributed to the need for the restraint.
- Alternative techniques that may have prevented the use of restraint.
- Procedures that staff might implement to prevent a reoccurrence.
- A discussion of the outcome of the intervention including injuries.
- Documentation of the debriefing, including the names of the participants, which documentation shall be recorded in the person's record.
Staff Training -
All staff shall be trained in appropriate restraint models as well as in prevention, trauma-informed care and the uses of restraint.
Each facility shall have a written plan for staff training and staff development, which includes but is not limited to,
- The use of emergency safety interventions.
- Verbal de-escalation.
- Prevention strategies.
- Types of emergency safety interventions.
- The differences between physical restraint, pain compliance techniques and permissible physical restraints.
- Monitoring procedures.
- Recording and reporting procedures.
- Maintenance of personal safety for the client and the staff.
- Medical and physical restrictions to be considered.
- Self protection, including escape and evasion.
- The continuum of least-to-most restrictive interventions.
- Approved techniques.
- Prohibited techniques.
- Debriefing and post-intervention activities.
- Safe escort and transport.
- Stages of crisis.
- Verbal limit setting.
- Understanding personal space, body language, and non-verbal communication.
- Consideration of child and adolescent development and cultural issues.
All staff shall be assessed at least annually to ensure continued competency in the use of restraint.
Policy and procedures shall be established for the utilization of staff who have been determined to be incapable of or unable to authorize, initiate, or participate in emergency safety interventions.
Data Collection and Reporting -
For each incident of serious injury, or the death of a client, that occurs during a restraint, the facility shall:
Immediately notify the Department's Hotline.
Within 48 hours send a completed DCF Form 136, Report of Suspected Child Abuse/Neglect, to the Department's Hotline.
File a report of the death or serious injury with the Department on a form provided by the Department for that purpose.
Provide copies of incident reports and medical reports regarding the incident and the medical follow-up to the Department.
Prohibited Practices -
No staff member shall use life-threatening physical restraint on a client.
No emergency safety intervention shall:
- include any restraint or hold in which the client experiences chest or back compression;
- include any restraint or hold in which the client is held face down with the arms crossed in front or behind the body, with or without chest or back compression;
- include the use of a latex glove or any other device or material to cover the client's mouth or include any technique, which may restrict the client's ability to speak or breathe;
- include any pressure to, or gripping of, the client's throat or neck;
- be used for punishment, discipline, or as a punitive measure;
- be used for the convenience of the provider;
- be used for the intentional infliction of pain or discomfort; and,
- be inconsistent with the client's treatment plan, individualized education plan or physician's orders.
Connecticut Department of Children and Families Effective Date: May 29, 2009 (New)
Content Last Modified on 6/1/2009 11:14:47 AM