(a) Special considerations. Before ordering restraint
or seclusion, the physician shall take the following into consideration:
(1) information about the individual that could contraindicate
or otherwise affect the use of restraint or seclusion;
(2) information obtained during the initial assessment
of each individual at the time of admission or intake, including,
but not limited to:
(A) pre-existing medical conditions or any physical
disabilities and limitations, including, without limitation, cognitive
functioning, substance use disorders, obesity, or pregnancy, that
would place the individual at greater risk during restraint or seclusion;
(B) any history of sexual abuse, physical abuse, neglect,
trauma, or previous restraint or seclusion that would place the individual
at greater psychological risk during restraint or seclusion;
(C) any history or trauma that would contraindicate
seclusion, the type of restraint (personal or mechanical), or a particular
type of restraint device for the individual;
(D) cultural factors; and
(E) information contained in a declaration for mental
health treatment, if there is one.
(b) Staff member responsibilities. Staff members shall:
(1) respect and preserve the rights of an individual
during restraint or seclusion. Rights of individuals are described
in Chapter 404, Subchapter E of this title (relating to Rights of
Persons Receiving Mental Health Services);
(2) provide an environment that is protected and private
from other individuals and that safeguards the personal dignity and
well-being of an individual placed in restraint or seclusion;
(3) ensure that undue physical discomfort, harm or
pain to the individual does not occur when initiating or using restraint
or seclusion;
(4) use only the amount of physical force that is reasonable
and necessary to implement a particular restraint or seclusion; and
(5) use psychoactive medication in an emergency only
in accordance with Chapter 414, Subchapter I of this title (relating
to Consent to Treatment with Psychoactive Medication--Mental Health
Services). Physically holding an individual during a forced administration
of a psychoactive medication, including for court-ordered medication,
constitutes personal restraint.
(c) Alternative strategies. The treatment team shall
review and, when appropriate, implement and document alternative strategies
for dealing with behaviors in each of the following circumstances:
(1) in any case in which behaviors have necessitated
the use of restraint or seclusion for the same individual more than
two times during the individual's facility or program admission, or
within any 30-day period, whichever period is shorter;
(2) when two or more separate episodes of restraint
or seclusion of any duration have occurred within the same 12 hour
period; and
(3) when an episode of restraint or seclusion has reached
the maximum time permitted under §415.261(b) of this title (relating
to Time Limitation on an Order for Restraint or Seclusion Initiated
in Response to a Behavioral Emergency).
(d) Treatment plan modification. If the circumstances
described in subsection (c)(1) - (3) of this section recur or continue
after treatment team review of alternative strategies under subsection
(c) of this section, the treatment team shall consult with the facility's
chief medical physician administrator or designee to explore alternative
treatment strategies and a written modification of the individual's
treatment plan.
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