|(a) Facility documentation. The facility shall document
the assessment, monitoring, and evaluation of an individual in restraint
or seclusion on a facility approved form. Documentation in an individual's
medical record shall include:
(1) the date and time the intervention began and ended;
(2) the name, title, and credentials of any staff members
present at the initiation of the intervention, with identification
of the staff member's role in the intervention, including as an observer,
or status as an uninvolved witness, as applicable;
(3) the name of the individual restrained or secluded
and the type of restraint or seclusion used;
(4) the time and results of any assessments, observation,
monitoring, and evaluations, including those required under this subchapter,
and attention given to personal needs;
(5) the physician's documentation of the order authorizing
restraint or seclusion in accordance with the requirements of §415.260
of this title (relating to Initiation of Restraint or Seclusion in
a Behavioral Emergency);
(6) any specific alternatives and less restrictive
interventions, including preventive or de-escalatory interventions
that were attempted by any staff member prior to the initiation of
restraint or seclusion, and the individual's response to any such
(7) the individual's response to the use of restraint
or seclusion; and
(8) other documentation relating to an episode of restraint
or seclusion otherwise required under this subchapter.
(b) Report to CEO. Staff members shall report daily
to the facility CEO or designee any use of a restraint or seclusion.
(1) The CEO or designee shall take appropriate action
to identify and correct unusual or unwarranted utilization patterns
on a systemic basis, and shall address each specific use of restraint
or seclusion that is determined or suspected of being improper at
the time it occurs.
(2) The CEO or designee shall maintain a central file
containing the following information:
(A) age, gender, and race of the individual;
(B) deaths or injuries to the individual or staff members;
(C) length of time the restraint or seclusion was used;
(D) types and dosage of emergency medications administered
during the restraint or seclusion, if any;
(E) type of intervention, including each type of restraint
(F) name of staff members who were present for the
initiation of the restraint or seclusion; and
(G) date, day of the week, and time the intervention
(c) Additional reporting in the case of death or serious
injury. By the next business day following an individual's death or
serious injury, facilities shall report the following information
to the appropriate entity designated in subsection (d) of this section.
(1) Each death or serious injury that occurs while
an individual is in restraint or seclusion;
(2) Each death that occurs within 24 hours after the
individual has been removed from restraint or seclusion; and
(3) Each death known to the facility that occurs within
one week after restraint or seclusion where it is reasonable to assume
that use of restraint or placement in seclusion contributed directly
or indirectly to a individual's death. "Reasonable to assume" in this
context includes, but is not limited to, deaths related to restrictions
of movement for prolonged periods of time, or death related to chest
compression, restriction of breathing, or asphyxiation.
(d) Reporting deaths or serious injury. Facilities
shall report the deaths or serious injuries of individuals in restraint
or seclusion as follows.
(1) Medicare- or Medicaid-certified facilities shall
report a death to the appropriate office for the Center for Medicare
and Medicaid Services in accordance with the federal death reporting
requirements relating to restraint and seclusion.
(2) Facilities that are neither Medicare- nor Medicaid-certified
shall report a death or serious injury to DSHS's medical director
for behavioral health.
(3) In addition to reporting in accordance with paragraphs
(1) and (2) of this subsection, all facilities licensed under Chapter
133 of this title (relating to Hospital Licensing) or Chapter 134
of this title (relating to Private Psychiatric Hospitals and Crisis
Stabilization Units) shall report a death or serious injury to the
Patient Quality Care Unit of DSHS's Division for Regulatory Services.
(4) Facilities shall comply with any additional reporting
requirements relating to restraint or seclusion to which they are
subject, including any applicable reporting requirements under The
Children's Health Act of 2000 and federal regulations promulgated
pursuant to the Act.
(e) Facility review of data. The facility shall review
and analyze, at least quarterly, the data that is required by subsection
(b)(2) of this section to identify and correct trends and patterns
that may contribute to the use of restraint or seclusion (e.g., disproportionate
use of restraint or seclusion with specific populations or shifts).
(f) Continuous improvement. The facility shall use
the data continuously to improve and ensure:
(1) a positive environment that minimizes the use of
an involuntary intervention;
(2) the safety of every individual and staff member;
(3) the use of restraint and seclusion is implemented
in accordance with the requirements of this subchapter;
(4) that the risks of injury and other negative effects
to individuals and staff members are reduced; and
(5) that policies and training curriculum incorporate
the requirements of this subchapter.
(g) On or before November 1, 2014, and quarterly thereafter,
any facility that is a Medicare or Medicaid provider shall submit
to DSHS the data required by Centers for Medicare and Medicaid Services
for hospital-based inpatient psychiatric service measures related
to the use of restraint or seclusion.
(h) On or before November 1, 2015, and quarterly thereafter,
a facility to which this subchapter applies shall prepare and submit
to DSHS a report, consistent with the Department
of State Health Services Behavioral Interventions Reporting Guidelines (guidelines)
available at: http://www.dshs.state.tx.us/Licensing-Facilities.shtm,
of the following data from the immediately preceding quarter:
(1) interventions used during a behavioral emergency,
(A) rate of seclusions (per 1,000 bed days);
(B) rate of personal restraints (per 1,000 bed days);
(C) rate of mechanical restraints (per 1,000 bed days);
(D) rate of emergency medication orders (per 1,000
(2) number of serious injuries related to an intervention
used in a behavioral emergency.
(3) number of deaths related to an intervention used
in a behavioral emergency.
(4) de-escalation techniques--description of all de-escalation
techniques commonly used by the facility in connection with any of
the emergency interventions described in paragraph (1) of this subsection.