Tenn. Comp. R. & Regs. 0250-04-08-.11

Current through May 9, 2024

Section 0250-04-08-.11 - SECLUSION AND RESTRAINT

(1) Physical Restraint

(a) Physical restraint is a restrictive intervention and one that poses a risk to the physical and/or psychological well-being of a youth and the safety of staff members. Physical restraint shall only be used in an emergency safety situation when the youth, due to current behavior, poses an imminent risk of harm to himself or herself or others. This applies to all youth in DCS licensed facilities regardless of adjudication. Physical restraint shall not be used as a means of punishment, discipline, coercion, convenience or retaliation or to compensate for lack of staff presence or competency.

(b) The following are not considered physical restraint and are acceptable:

1. Physical touch associated with prompting, comforting or assisting that does not prevent the youth's freedom of movement or normal access to his or her body;

2. Physical or temporary touching or holding of the hand(s), wrist(s), arm(s), shoulder(s) or back for the purpose of inducing the youth to walk to a safe location; or

3. Physical intervention for the temporary holding of the hand(s), wrist(s), arm(s), shoulder(s), or leg(s) which does not otherwise restrict freedom of movement or access to one's body, for the purpose of terminating unsafe behavior.

(c) Use of physical restraint should be restricted as follows:

1. Physical restraint is an emergency safety intervention, not a therapeutic technique, and shall be implemented in a manner designed to protect the youth's safety, dignity and emotional well-being.

2. There shall be sufficient staffing to ensure appropriate supervision of all other youth while trained staff devote full time and attention to all uses and phases of physical restraint.

3. The use of physical restraint is allowed only in the case of an emergency, when the youth is at imminent danger of self-harm or of harming others and no other option exists to protect the safety of the youth and staff members.

4. In a facility setting, physical restraint may also be justified to prevent a clear and immediate escape attempt.

5. Clothing shall not be removed from a youth in conjunction with the use of physical restraint or seclusion, other than that which is determined to place the youth or others at risk.

(d) Training Requirements

1. All staff who use physical restraint shall be trained prior to performing these interventions and annually thereafter by a certified trainer in a nationally recognized crisis intervention program.

2. The training shall involve a post-test and the observation of staff in practice to ensure competency.

3. Records of staff completion of training shall be maintained and made available to DCS licensing upon request.

4. Training shall address prevention of the use of restrictive behavior management techniques through a curriculum that includes the following:

(i) Recognizing aggressive and out-of-control behavior, psychosocial issues, medical conditions, and other contributing factors that may lead to crisis;

(ii) Understanding how staff behavior can influence the behavior of youth;

(iii) Understanding the limitations of restrictive behavior management techniques such as physical restraint or seclusion;

(iv) Listening and communication techniques such as negotiation and mediation;

(v) Involving the youth in regaining control and encouraging self-calming behaviors;

(vi) Separation of individuals involved in an altercation;

(vii) Voluntarily escorting the youth to a safe location;

(viii) Voluntary time out to allow the youth to calm down; and

(ix) Other non-restrictive methods to de-escalate and reduce episodes of aggressive and out-of-control behavior.

5. At the conclusion of training, staff shall demonstrate an understanding of:

(i) When it is appropriate to use a restrictive intervention such as physical restraint or seclusion;

(ii) Safe use of physical restraint and seclusion, including time limits;

(iii) Safe methods for escorting youth;

(iv) The experience of being placed in a physical restraint or in seclusion;

(v) Signs of distress;

(vi) Response techniques to prevent and reduce injury;

(vii) Negative effects that can result from misuse of restrictive interventions;

(viii) Physical and mental status of the youth, including signs of physical distress;

(ix) Nutritional and hydration needs of the youth;

(x) Readiness to discontinue use of the physical restraint or seclusion; and

(xi) Recognizing when medical or other emergency personnel are needed.

(e) Authorization and Initiation of Physical Restraint

1. The staff member initiating the physical restraint shall contact the facility administrator or their qualified designee to authorize the intervention either prior to the intervention, or if prior permission is impracticable due to the emergent nature of the situation, immediately following the intervention. While it is best practice to obtain this authorization prior to the intervention, this is not always possible when handling the types of emergencies requiring the use of physical restraint.

2. Authorization of intervention: Staff members may authorize physical restraint or seclusion only if they are supervisory level staff who have completed all training requirements in compliance with this part prior to authorizing physical restraint or seclusion and have been designated as having authority to make such decisions in an emergency setting by the facility administrator. In a Juvenile Detention Center this shall be a shift supervisor or higher ranking personnel.

3. A new authorization is required if there is a change in the intervention utilized. If the use of physical restraint has been discontinued, it may be used again only with a new authorization, even if a previously authorized time limit has not expired.

4. Authorizations for the use of physical restraint are time-limited up to fifteen (15) minutes for youth age nine (9) years and under and up to thirty (30) minutes for youth ages ten (10) years and over. Physical restraints lasting longer than the allowed time frames require clinical justification, which shall be obtained through direct evaluation of the youth by mobile crisis staff or other qualified clinical personnel for continuation and require a new authorization.

5. The re-authorization of interventions that exceed the initial time limits shall be from mobile crisis staff or other qualified clinical personnel. Physical restraint can be authorized for up to an additional thirty (30) minutes.

6. Time-limited authorizations do not mean that the use of restrictive behavior management interventions shall be applied for the entire length of time for which the authorization is written. Physical restraint and seclusion shall be used only for the minimum amount of time necessary.

(f) Monitoring and Assessment

1. A youth in a physical restraint shall be assessed and monitored continuously by a properly trained staff member not involved in the restraint. If a second staff member is not present at the moment the restraint is initiated, staff shall immediately call for help so that another staff member may begin monitoring.

2. Physical restraints shall be monitored by direct visual observation and staff shall remain in the immediate physical presence of and in the same room as the youth. Video monitoring does not meet this requirement.

3. In addition to monitoring the youth on a continuous, face-to-face basis, staff shall assess the child/youth every 15 minutes for:

(i) Any harmful health effects or signs of any injury associated with the intervention;

(ii) Emotional status and comfort;

(iii) Need for food, water, and use of bathroom facilities;

(iv) Readiness to discontinue the intervention; and

(v) Difficulty breathing and any other physical complaints that may signal the need to discontinue the intervention.

(g) Termination of Restraint and Follow-Up Assessment

1. A physical restraint shall only be used for the minimum time possible. These interventions shall be terminated when the behavior justifying their use no longer exists or if the face-to-face assessments required by this rule do not occur. Immediate release shall occur if there is any threat to the youth's physical or emotional well-being.

2. Within one (1) hour of the initiation of the use of physical restraint, the staff member authorizing the seclusion or restraint, in accordance with 0250-07-08-.11(5)(b), shall assess the youth's condition and shall make a determination whether to continue the restraint. This assessment shall be conducted regardless of the length of time the youth is in the physical restraint.

(h) Whenever a youth is injured as a result of the use of physical restraint, staff shall immediately obtain medical treatment for that youth.

(i) The youth and staff shall participate in a debriefing about the physical restraint episode as soon as possible, but no longer than twenty-four (24) hours after the intervention occurred. The debriefing shall occur in a safe, confidential setting. The debriefing with the youth and staff is used to:

1. Ascertain that the youth's physical well-being, emotional comfort, and right to privacy were addressed;

2. Identify any trauma that may have resulted from the incident and identify services to address the trauma;

3. Identify what led to the emergency safety situation and what could have been handled differently;

4. Facilitate the youth's reentry into routine activities;

5. Discuss what precipitating events led to the intervention, how the incident was handled, and discuss any necessary changes to procedures or training to avoid future incidents; and

6. When deemed necessary, a debriefing shall take place with any youth or other individuals who witnessed the incident, with an emphasis placed on returning the environment to pre-incident condition and resuming the normal program routine.

(j) Notification and Documentation

1. Documentation shall include the following:

(i) A clear description of the events and behavior leading to the initiation of the physical restraint, including the specific risk of harm presented by the youth;

(ii) A description of attempts by staff to prevent and de-escalate the youth prior to utilizing physical restraint;

(iii) Names of the youth and staff members involved;

(iv) Duration of intervention;

(v) Verification of continuous observation and fifteen (15) minute checks;

(vi) A description of all injuries that occurred because of the intervention; and

(vii) A note that debriefing occurred.

2. Whenever possible, the youth's parents or legal guardian shall be notified of the occurrence of any physical restraint or seclusion.

(k) Internal Review

1. The facility shall engage in ongoing performance improvement activities that focus on the reduction of the use of physical restraint. Information obtained through the review processes shall be considered, at least quarterly, in the identification of specific performance improvement activities and in the evaluation of the effectiveness of performance improvement activities.

2. Facilities shall review data throughout the year to identify trends in use of restrictive behavior management techniques in order to reduce the use of physical restraint.

3. The facility shall ensure that a routine process is in place to address the use of crisis intervention and physical restraint in individual and/or group supervision with all direct service and clinical staff. Such supervision shall focus on analyzing individual interventions as well as patterns of intervention to identify ways to increase the effective use of prevention methods and further reduce the use of physical restraint.

(2) Chemical Defense Agents

(a) Facilities shall have written policy and procedure which govern the availability, control and use of chemical defense agents. The policies shall include specific guidelines that determine the level of authority needed to access and use chemical defense agents and the procedures required to authorize their use. The policy should also include medical and/or decontamination procedures that will be followed in all instances involving the use of a chemical defense agent.

(b) The use of chemical defense agents in all Temporary Holding Resources is prohibited except by law enforcement personnel.

(c) Use of chemical defense agents should be restricted as follows:

1. Use of chemical defense agents is an emergency intervention and every effort will be made to protect the youth's safety, dignity and emotional well-being during its use.

2. There will be sufficient staffing to ensure appropriate supervision of all other youth while trained staff devote time and attention to use of chemical defense agents.

3. If a second staff member is not present at the moment the intervention is initiated, staff shall immediately call for assistance so that another staff member may being monitoring.

4. The use of chemical defense agents is allowed only in the case of an emergency, when the youth is at imminent danger of self-harm or of harming others and no other option exists to protect the safety of the youth and staff members.

5. Only those staff designated by the administrator and trained in their use shall be authorized to deploy chemical defense agents.

(d) Training Requirements

1. All staff who use chemical defense agents must be trained prior to performing these interventions and annually thereafter by a certified trainer in a nationally recognized crisis intervention program. Training through local law enforcement resources is acceptable.

2. The training must involve a post-test and the observation of staff in practice to ensure competency.

3. Records of staff completion of training will be maintained and made available to DCS licensing upon request.

(e) Authorization for Intervention Involving Chemical Defense Agents

1. The staff member initiating the use of chemical defense agents will contact the facility administrator or their qualified designee to authorize the intervention either prior to the intervention, or if prior permission is impracticable due to the emergent nature of the situation, immediately following the intervention. While it is best practice to obtain this authorization prior to the intervention, it is noted that this is not always possible when handling emergencies requiring the use of chemical defense agents.

2. Authorization of intervention: Staff members may authorize the use of chemical defense agents only if they are supervisory level staff who have completed all training requirements in compliance with this part prior to authorizing intervention, and have been designated as having authority to make such decisions in an emergency setting by the facility administrator. In a Juvenile Detention Center this will be a shift supervisor or higher ranking personnel.

3. Once the use of chemical defense agents has been discontinued, it may be used again only with a new authorization.

4. A list of all staff members issued chemical defense agents or authorized in their use must be maintained and updated upon change of authorization status or employment.

(f) Treatment, Assessment, and Monitoring

1. Following the use of chemical defense agents, decontamination procedures and any necessary medical treatment shall be administered immediately. Staff shall arrange for a youth to be moved to an area offering fresh air and given a shower and change of clothing. All body parts exposed to Oleoresin Capsicum (OC) spray will be thoroughly rinsed with water. Staff shall assist youth in flushing eyes.

2. The affected youth shall be assessed and monitored continuously by a properly trained staff member not directly involved in the deployment of chemical defense agents. Monitoring shall continue until symptoms disappear to ensure medical attention is administered when necessary. Physical effects of exposure to OC sprays include: tearing, involuntary closing of eyes, redness of skin, coughing, gagging, shortness of breath or loss of motor skills or coordination.

3. In addition to monitoring the youth on a continuous, face-to-face basis, staff shall assess the youth every fifteen (15) minutes for:

(i) Any harmful health effects or signs of any injury associated with the intervention;

(ii) Emotional status and comfort of the youth;

(iii) The youth's need for food, water, and use of bathroom facilities; and

(iv) Difficulty breathing and any other physical complaints that may signal the need for medical treatment.

4. Medical treatment shall immediately be obtained for a youth if:

(i) The youth shows symptoms for more than thirty (30) minutes after decontamination;

(ii) More than a slight reddening of the youth's skin occurs following exposure;

(iii) The youth complains of inordinate pain or requests medical care following decontamination; or

(iv) The youth has a known history of respiratory illness, allergies, or asthma.

5. The affected youth shall be monitored by direct visual observation and staff will remain in the immediate physical presence of and in the same room as the youth. Video monitoring shall not be used to meet this requirement.

(g) The youth and staff will participate in a debriefing about the episode as soon as possible, but no longer than twenty-four (24) hours after the intervention occurred. The debriefing will occur in a safe, confidential setting. The debriefing with the youth and staff is used to:

1. Ascertain that the youth's physical well-being was appropriately addressed;

2. Identify any trauma that may have resulted from the incident and identify services to address the trauma;

3. Identify what led to the emergency safety situation and what could have been handled differently;

4. Facilitate the youth's reentry into routine activities;

5. Discuss what precipitating events led to the intervention, how the incident was handled, and discuss any necessary changes to procedures or training to avoid future incidents; and

6. When deemed necessary, a debriefing will take place with any youth or other individuals who witnessed the incident, with an emphasis placed on returning the environment to pre-incident condition and resuming the normal program routine.

(h) Notification and Documentation

1. A written incident report shall be submitted to the facility administrator by the end of the shift when a chemical defense agent is used that includes the following:

(i) A clear description of the events and behavior leading to the initiation of the intervention, including the specific risk of harm presented by the youth;

(ii) A description of attempts by staff to prevent and de-escalate the youth prior to utilizing chemical defense agents;

(iii) Names of the youth and staff members involved;

(iv) Time and duration of intervention; including decontamination;

(v) Verification of continuous observation and fifteen (15) minute checks;

(vi) A description of all injuries that occurred because of the intervention; and

(vii) A note that debriefing occurred.

2. Whenever possible, the youth's parents or legal guardian will be notified of the occurrence of any use of chemical defense agents.

(i) Internal Review

1. The facility shall engage in ongoing performance improvement activities that focus on the reduction of the use of chemical defense agents. Information obtained through the review processes will be considered, at least quarterly, in the identification of specific performance improvement activities and in the evaluation of the effectiveness of performance improvement activities.

2. Facilities shall review data throughout the year to identify trends in use of restrictive behavior management techniques in order to reduce the use of chemical defense agents.

3. The facility will ensure that a routine process is in place to address the use of crisis intervention and use of chemical defense agents in individual and/or group supervision with all direct service and clinical staff. Such supervision will focus on analyzing individual interventions as well as patterns of intervention to identify ways to increase the effective use of prevention methods and further reduce the use of chemical defense agents.

(j) Chemical defense agents maintained and used by facility staff are limited to OC sprays and may not contain Mace.

(k) Reasonable efforts must be made to remove a youth with documented or known respiratory conditions (including asthma, bronchitis, etc.) prior to the chemical defense agents being dispersed in any area in which the youth may be affected.

(l) Only the minimum amount of chemical defense agent will be used to control the youth's behavior. All canisters containing chemical defense agents will be weighed monthly and immediately following each use. Documentation of both routine inspection and incidental use will be documented for administrative review by the licensing staff or facility administrator.

(m) Written policy and procedure shall require that chemical defense agents are inventoried monthly and tested at least quarterly to determine their condition and expiration dates.

(n) Chemical defense agents will be stored in a locked cabinet inaccessible to youth when not issued or in use.

(o) Any intentional time lapse between the administering of chemical defense agents and subsequent appropriate decontamination or medical attention for punitive purposes is prohibited.

(p) Psychotropic medication shall not be used for the purposes of chemical restraint in any Juvenile Detention Center or Temporary Holding Resource.

(3) Mechanical Restraints

(a) Mechanical restraints, e.g. handcuffs and shackles, shall only be used to restrain youth who are alleged to be delinquent and meet the criteria for secure detention listed in T.C.A. § 37-1-114 (2016 and as amended). Staff shall maintain visual contact at all times with youth in mechanical restraints.

(b) Mechanical restraints may only be used for such time as it takes to place the child in a secure cell, or for transportation. Waist belts are permitted for transportation only.

(c) Body wraps and restraint beds are strictly prohibited. Use of restraint chairs shall be prohibited effective July 1, 2018. Use of mechanical restraints on pregnant youth shall be limited to wrist restraints only. Temporary, short-term use of security benches or mechanical restraints during classification or preparation for transport is permitted.

(d) The facility shall have written policy and procedure which outline the specifics of non-routine use of mechanical restraints and include language that requires the authorization of the shift supervisor before the mechanical restraint may be used.

(e) With the exception of law enforcement personnel, the possession/use of tasers and related "less lethal" designated equipment (such as Nova stun shields) is prohibited in any facility. Possession or use of such equipment by facility staff shall result in immediate adverse licensing action up to suspension of the agency's license.

(f) Mechanical restraints shall never be used as punishment.

(g) Whenever mechanical restraints are used for reasons other than transportation, the facility's written policy, procedure and practice shall provide that prior approval shall be obtained from the facility administrator, or designee. When a youth is mechanically restrained for reasons other than transportation, the following minimum procedures shall be followed:

1. Continuous, direct visual observation by staff;

2. Safety and wellness checks shall be conducted and documented every ten (10) minutes, to ensure the safety and well-being of the youth; and

3. Use of mechanical restraints shall be fully documented as to time, duration, reasons, authority and witnesses and reported to the facility administrator or designee.

(4) With the exception of use by law enforcement personnel, the following restraint techniques shall not be used within any facility licensed by the Department:

(a) Restricting respiration in any way, such as applying a chokehold or pressure to a youth's back or chest or placing a youth in a position that is capable of causing positional asphyxia;

(b) Using any method that is capable of causing loss of consciousness or harm to the neck;

(c) Pinning down with knees to torso, head, and/or neck;

(d) Using pressure point, pain compliance, and joint manipulation techniques, other than an approved method for release of a chokehold, bite, or hair pull;

(e) Modifying restraint equipment or applying any cuffing technique that connects handcuffs behind the back to ankle restraints;

(f) Lifting a youth's arms behind the back, while in mechanical restraints, in a manner that is capable of causing injury to the shoulder;

(g) Using other youth or untrained staff to assist with the restraint;

(h) Securing a youth to another youth; and

(i) Administering a drug for controlling acute episodic behavior as a means of physical restraint, except when the youth's behavior is attributable to mental illness and the drug is authorized by a licensed physician and administered by a licensed medical professional.

(5) Seclusion

(a) Seclusion is often associated with physical restraint in that physical restraint is regularly used to transport youth to a seclusion environment. However, seclusion may occur without employing physical restraint. All precedent used by staff in avoiding the need for restraint should also be employed to avoid the need for seclusion.

(b) Seclusion does not include:

1. The segregation of a youth for the purpose of managing biological contagion consistent with the Centers for Disease Control Guidelines.

2. Confinement to a locked unit or ward where other youth are present. Seclusion is not solely confinement of a youth to an area, but separation of the youth from other persons.

3. Voluntary time-out involving the voluntary separation of an individual youth from others. The youth is allowed to end the separation at will.

4. Seclusion in a facility setting does not include temporarily securing youth in their rooms during regularly scheduled times (such as periods set aside for sleep or regularly scheduled down time) that are universally applicable to the entire population or within the youth's assigned living area.

(c) Seclusion may be provided only in a clean, dry, temperate location that is free of potentially hazardous conditions which might harm the youth or others. Rooms used for seclusion shall allow staff full view of the youth in all areas of the room. The room shall have the following qualities:

1. The room is lighted and well ventilated;

2. Light fixtures are screened or recessed, interior doorknobs are removed, and hinges are recessed;

3. The room is at a minimum fifty (50) square feet in area;

4. The room is unfurnished and may have padding that is designed specifically for use in psychiatric or similar settings and approved by the local health and fire authorities;

5. The room contains an observation window the dimensions of which permit a youth to be in view regardless of where he/she is positioned in the room;

6. The room is inspected and approved under regulations adopted by the State Fire Marshal prior to usage; and

7. Youth in seclusion have reasonable access to water, toilet facilities and hygiene supplies.

(d) Monitoring of seclusion shall be by direct in-person (face-to-face) visual observation through the seclusion room window or in the room itself every fifteen (15) minutes.

(e) Seclusion of youth for suicidal behavior/ideation or other clinical reasons shall be conducted as provided in 0250-04-08-.07(1).

(f) All other referrals for seclusion shall adhere to the following guidelines:

1. Seclusion shall only be used when necessary to prevent imminent harm to themselves, another person, prevent damage to property, or prevent the youth from escaping.

2. Staff shall never use seclusion for discipline, punishment, administrative convenience, retaliation, staffing shortages, or reasons other than a temporary response to behavior that threatens immediate harm to a youth or others.

3. Prior to using seclusion, staff shall use less restrictive techniques, including talking with youth to de-escalate the situation. Prior to using seclusion or immediately after placing a youth in seclusion, staff shall explain to the youth the reasons for the seclusion and the fact that he or she shall be released upon regaining self-control. Once the youth no longer presents a risk of imminent harm to themselves or others at the facility, the seclusion shall be terminated and the youth shall be returned to the general population.

4. Seclusion lasting over twenty-four (24) hours shall be reviewed and approved at the twenty-four (24) hour mark and every subsequent twenty-four (24) hour period by the facility administrator. Youth may not be secluded for more than seventy-two (72) total hours within any fourteen (14) day period. Large muscle group exercise must be provided a minimum of one (1) hour daily for those juveniles in seclusion longer than twenty-four (24) hours.

5. A hearing shall be held within twenty-four (24) hours of initial confinement for any seclusion lasting more than one (1) hour. Any seclusion lasting longer than twenty-four (24) hours requires an additional administrative hearing in which the youth may appeal continued confinement prior to the extension of confinement. The hearing shall be conducted by the administrator or his established hearing officer and all proceedings shall be documented. A written copy of this documentation shall be provided to the youth and the youth's parent or legal guardian.

6. An incident report shall be completed within twenty-four (24) hours for any youth referred for seclusion. Youth may be placed in their room for a "cooling off" period not to exceed one (1) hour without need for incident report. Staff may allow the "cooling off" period to extend an additional hour, for a total of two (2) hours, however if the youth's placement in their room under this part extends for longer than two (2) hours the youth shall be considered secluded and an incident report must be completed. Such action, including the precipitating behavior/event, shall be documented.

7. Youth placed in seclusion shall be offered reasonable access to services and shall be engaged in regularly scheduled programming unless they are an immediate threat to others.

Tenn. Comp. R. & Regs. 0250-04-08-.11

New rules filed March 17, 2017; effective 6/15/2017.

Authority: T.C.A. §§ 37-5-105; 37-5-106; and 37-5-501, et. seq.