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RULE §448.706Restraint and Seclusion

(a) A small residential facility is defined as a treatment facility with less than eight licensed beds.

(b) The governing body shall adopt a policy to either authorize or prohibit the use of personal restraint, mechanical restraint, and seclusion. Any facility authorizing use of restraint or seclusion shall comply with and have a written procedure that ensures compliance with Health and Safety Code, Chapter 322, including its definition of seclusion; the rules adopted under that chapter; and this section. Outpatient programs shall prohibit the use of restraint or seclusion, except as it relates to court commitment clients.

(c) In programs authorizing use of restraint or seclusion, direct care staff shall be trained as described in the applicable provisions of §448.603 of this title (relating to Training). Staff sufficient in number and who have the training required by §448.603 of this title to safely implement any permitted restraint or seclusion shall be on duty at all times.

(d) Staff shall not use restraint or seclusion unless it is necessary to intervene to prevent imminent probable death or substantial bodily harm to the client or imminent physical harm to another and less restrictive methods have been tried and failed.

(e) Staff shall not use more force than is necessary to prevent imminent harm and shall ensure the safety, well-being, and dignity of clients who are restrained or secluded, including attention for personal needs. Staff shall not deny bathroom privileges, water, sleep, or regularly scheduled meals and snacks.

(f) Staff shall obtain authorization from the supervising Qualified Credentialed Counselor (QCC) before starting restraint or seclusion or as soon as possible after initiation or implementation.

  (1) The facility shall not use standing authorizations for restraint or seclusion.

  (2) Authorization for mechanical restraint or seclusion shall be based on a face-to-face evaluation by the authorizing QCC, if on site or reasonably available, or by the direct care staff initiating or implementing the procedure.

  (3) Each authorization shall include a specific time limit, not to exceed 12 hours.

  (4) The QCC must take into consideration information that could contraindicate or otherwise affect the use of restraint or seclusion, including information obtained during the initial assessment of each client at the time of admission or intake. This information includes, but is not limited to:

    (A) techniques, methods, or tools that would help the client effectively cope with his or her environment;

    (B) pre-existing medical conditions or any physical disabilities and limitations, including substance use disorders, that would place the client at greater risk during restraint or seclusion;

    (C) any history of sexual or physical abuse that would place the client at greater psychological risk during restraint or seclusion; and

    (D) any history that would contraindicate seclusion, the type of restraint (personal or mechanical), or a particular type of restraint devise.

(g) When the client has been safely restrained or secluded, staff shall tell the client what behavior and timeframes are required for release and shall release the client as soon as the criteria are met.

(h) Clinical staff shall review and document alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion for an individual client two or more times in any 30-day period.

(i) The chief executive officer of the facility or designee shall review all incident reports involving restraint or seclusion and take action to address unwarranted use of these measures.

(j) A client held in restraint shall be under continuous direct observation. The facility shall ensure adequate breathing and circulation during restraint and shall only use devices designed for therapeutic restraint. An acceptable hold is one that engages one or more limbs close to the body to limit or prevent movement and is performed in a manner consistent with the requirements set forth in this section.

(k) Seclusion rooms shall be constructed to prevent clients from harming themselves and shall allow staff to observe clients easily in all parts of the room. When a client is in seclusion, staff shall conduct a visual check at least every 15 minutes.

(l) Staff shall record the following information in the client record within 24 hours:

  (1) the circumstances leading to the use of restraint or seclusion;

  (2) the specific behavior necessitating the restraint or seclusion and the behavior required for release;

  (3) less restrictive interventions that were tried before restraint or seclusion began;

  (4) the signed authorization of the supervising QCC;

  (5) the names of the staff members who implemented the restraint or seclusion;

  (6) the date and time the procedure began and ended;

  (7) the behavior and timeframes required for release;

  (8) the client's response;

  (9) observations made, including the 15 minute checks; and

  (10) attention given for personal needs.

(m) A prone or supine hold shall not be used except as a last resort when other less restrictive interventions have proven to be ineffective. The hold shall be used only to transition a client into another position, and shall not exceed one minute in duration. Except in small residential facilities, when the prone or supine hold is used, an observer, who is trained to identify the risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds, and who is not involved in the restraint, shall ensure the client's breathing is not impaired.

(n) No intervention, voluntary or involuntary, shall be used:

  (1) as a means of discipline, retaliation, punishment, or coercion;

  (2) for the purpose of convenience of staff members or other individuals; or

  (3) as a substitute for effective treatment.

(o) A restraint shall not be used that:

  (1) secures a client to a stationary object while the client is in a standing position;

  (2) causes pain to restrict a client's movement (pressure points or joint locks);

  (3) restricts circulation;

  (4) obstructs a client's airway, including a procedure that places anything in, on, or over a client's mouth or nose or puts pressure on the torso;

  (5) impairs a client's breathing;

  (6) interferes with a client's ability to communicate; or

  (7) is inconsistent with training received in compliance with §448.603 of this title (relating to Training).

(p) Use of chemical restraint is prohibited.

(q) Use of restraint or seclusion solely as a behavior therapy program or as part of a behavior therapy program is prohibited.

(r) Immediately following the release of a client from restraint or seclusion, a direct care staff must:

  (1) take appropriate action to facilitate the client's reentry into the facility environment by providing the client with transition activities and an opportunity to return to ongoing activities;

  (2) observe the client for at least 15 minutes; and

  (3) document observations of the client's behavior during this transition period in the client's record.

(s) As soon as possible after an episode of restraint or seclusion, staff members involved in the episode, supervisory staff, the client, the legally authorized representative, if any, and, with the consent of the client, family members must meet to discuss the episode. The purpose of the debriefing is to:

  (1) identify what led to the episode and what could have been handled differently;

  (2) identify strategies to prevent future restraint or seclusion, taking into consideration suggestions from the client;

  (3) ascertain whether the client's physical well-being, psychological comfort, and right to privacy were addressed;

  (4) counsel the client in relation to any trauma that may have resulted from the episode;

  (5) when indicated, identify appropriate modifications to the client's treatment plan; and

  (6) when clinically indicated or upon request of individuals who witnessed the restraint debrief persons who witnessed the restraint.

Source Note: The provisions of this §448.706 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective June 1, 2006, 31 TexReg 4433

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