Chapter 5 - Urgent Events & Emergencies

Restraint

A. Policy
Hillcrest Educational Centers is committed to providing children and youth served with a safe environment and to address their treatment issues by using appropriate and effective therapeutic techniques in the most positive and the least restrictive and aversive manner possible.

Restraint is utilized only as an emergency intervention of last resort after other lawful and less intrusive alternatives have failed or been deemed inappropriate.

Restraint is only utilized when a student’s behavior presents the risk of assault or imminent, serious, physical harm or injury to self or others.

Staff will implement proper use of restraint to prevent or minimize any harm to the student as a result of the use of physical restraint.

If the use of restraint becomes necessary as an emergency intervention of last resort, it will be executed in a cautious manner consistent with the procedures defined within the crisis intervention system(s) in use by Hillcrest Educational Centers.

Prone Restraint shall not be used unless permitted pursuant to 603 CMR 46.03(1)(b) on an individual student basis and only under the following circumstances:

  • The student has a documented history of repeatedly causing serious self-injuries and/or injuries to other students or staff;
  • All other forms of physical restraints have failed to ensure the safety of the student and/or the safety of others;
  • There are no medical contraindications as documented by a licensed physician;
  • There is psychological or behavioral justification for the use of prone restraint and there are no psychological or behavioral contraindications, as documented by a licensed mental health professional;
  • The program has obtained consent to use prone restraint in an emergency as set out in 603 CMR 46.03(1)(b), and such use has been approved in writing by the Program Director; and,
  • The program has documented 603 CMR 46.03(1)(b) 1 – 5 in advance of the use of prone restraint and maintains the documentation.

 

This policy and these procedures are consistent with, and meet or exceed, all associated regulations of the Massachusetts Department of Early Education and Care (DEEC) and the Massachusetts Department of Elementary and Secondary Education (DESE), as well as associated standards promulgated by the Joint Commission.
Hillcrest defines restraint as direct physical contact that prevents or significantly restricts a student’s freedom of movement, in accordance with state regulations. Physical restraint does not include: brief physical contact to promote student safety, providing physical guidance or prompting when teaching a skill, redirecting attention, providing comfort, or a physical escort. Any restraint lasting more than 20 minutes is referred to as an “extended restraint”.
B. Restraint Oversight and Management; Performance Improvement
At all levels of the organization, Hillcrest takes steps to minimize and reduce the use of and duration of restraint while maintaining a safe environment for students and staff. Hillcrest’s Board of Directors and Senior Management Team, which includes the CEO/President, Executive Director and/or Senior Vice President, Program Director, and Department Heads, use the frequency of restraint as one indicator of quality of care and organizational performance.
Hillcrest’s management understands the potential risks associated with these interventions. Therefore, each Hillcrest program site maintains data on the use of all physical interventions on computer software designed by Hillcrest’s Information Services Department. This data describes the use of restraints by student, staff member, and time of day. The data are reviewed regularly by each program’s Improving Organizational Performance Committee and by the Senior Management Team of the agency. Analyses of this data are included in each program’s Improving Organizational Performance quarterly report to administration and the Board of Directors. The information is also analyzed quarterly by the agency’s Information Services department, and each quarter restraint data is submitted to the Massachusetts Department of Early Education and Care (DEEC), as required. Furthermore, use of restraint is reported to the Massachusetts Department of Elementary and Secondary Education (DESE) in accordance with state regulation.
Management staff at all levels review the data to ensure that proper procedures are followed, including the use of alternative interventions, and that the rights, dignity and well-being of students are maintained. Hillcrest staff are only authorized to use protective and physical interventions techniques that are part of the crisis prevention and intervention model that is endorsed for use. The current model in use is Therapeutic Crisis Intervention.
The Program Director/Program Manager/Program Manager of each Hillcrest program serves as the Restraint Coordinator for that site. He/she is ultimately responsible for leading efforts to minimize the use of restraint, and for ensuring that the use of restraint complies with both state regulations and Joint Commission standards. The agency Performance Improvement Coordinator coordinates the efforts at all program sites to reduce the use of restraint and monitor the safety and effectiveness of restraint techniques in compliance with Hillcrest restraint use policy.
The Improving Organizational Performance Committee (IOP) and the Student Treatment and Intervention Committee (STIC) for each site serve as Restraint Review Committees for that site. They share, with the Program Director, the responsibility for oversight and management of behavioral/ physical interventions. STIC membership generally includes, but is not limited to; agency Performance Improvement Coordinator, program administration, members of the clinical department, and direct care staff. Finally, Hillcrest’s Human Rights and Organizational Ethics Committee (HROE) monitors trends associated with possible violations of human rights or organizational ethics.
C. Restraint Authorization Procedures

Restraint is utilized only as an emergency intervention of last resort after other lawful and less intrusive alternatives have failed or been deemed inappropriate.

Restraint is only utilized when a student’s behavior presents the risk of assault or imminent, serious, physical harm or injury to self or others.

Staff will implement proper use of restraint to prevent or minimize any harm to the student as a result of the use of physical restraint.
1. Assessment at Admission

 

 

During the initial clinical assessment following admission to the agency, clinicians evaluate the potential for situations that could require the restraint of the student. Alternatives to restraints are outlined in detail. An Individualized Crisis Management Plan (ICMP) is developed for each student in care. Programs that use Applied Behavior Analysis will also develop comprehensive Behavior Support Plans for each student. These plans are used by staff to support students in behavioral crisis and identify how to effectively respond to meet the needs of the child. They focuses on the prevention of a crisis, as well as the physical techniques that are appropriate for use should the student exhibit behaviors that present a danger to themselves or others.
Any clinical plan to restrain the student as needed must be based on the reasonably anticipated and/or demonstrated behavior of the student within the Hillcrest environment. An LP order to restrain will not be based solely on the student’s restraint history or his/her history of dangerous behaviors. This initial assessment must be thoughtful and clear since it stands as clinical justification for emergency situations when a licensed practitioner may not be present. Additionally, the psychiatrist will evaluate the child’s risk of danger in the initial psychiatric report. When appropriate, this evaluation will include an LP order to restrain, as needed.

 

 

2. Restraint Prevention

 

 

Staff should utilize all individual treatment approaches, interventions and de-escalation techniques geared toward preventing or defusing volatile situations that may require the physical restraint of a student. The development of positive relationships between the student and staff, the recognition of staff own feelings in a crisis, the identification of the students’ needs, the focus on managing the environment, the teaching of skills, and the avoidance of conflict cycles created by staff to exert control are some of the effective ways to prevent a behavioral crisis and avoid the use of a restraint.
3. The Individualized Crisis Management Plan

 

 

Staff are required to utilize the Individualized Crisis Management Plan (ICMP) to effectively respond to the student’s needs in a behavioral crisis. The ICMP is an individualized plan specific to each student that is created at time of admission and updated minimally every three months as part of the treatment plan review process. The first section of the ICMP is a student-centered safety plan and the second section is a staff generated crisis prevention and intervention plan. The ICMP identifies specific student behaviors at each stage of their stress model of crisis and identifies how staff should respond at each stage to meet the needs of the students. The ICMP also contains information regarding the restraint techniques that could be utilized in an emergency should the student present an imminent danger of serious harm to themselves or others and all other interventions have failed. Restraint restrictions based on medical or psychological contraindications are also included. Input on the creation of the ICMP is obtained from the student, their family, and staff within the milieu.
4. Authorization to Initiate a Restraint; Ordering a Restraint

 

 

Only staff who have been trained in and successfully completed the initial 28 hour Therapeutic Crisis Intervention course and who have demonstrated competence in evaluating immediate danger and in applying restraint techniques in a safe and appropriate manner may initiate the restraint of a student.
The decision to initiate the restraint of a student by an authorized staff member is based on the emergent and immediate danger presented by the student to self or others. The order to restrain a student, or to continue a restraint that has been initiated, is made only by a licensed practitioner (LP). The Joint Commission defines a licensed practitioner as an individual who is permitted by law, and by the organization based on job description, to provide student care services within the scope of his/her license and job description.
Orders for restraint or for continuation of a restraint that has been initiated may be verbal or written. Verbal LP orders must be approved in writing within 24 hours. Licensed practitioners have the obligation to review the use of restraint as it relates to students for whom they are responsible.

 

5. Maintaining Student and Program Safety

 

If a student is unwilling or unable to respond to verbal and/or less restrictive interventions and he/she demonstrates behaviors which constitute an immediate danger of serious harm to self or others, authorized staff may initiate a physical restraint as an emergency intervention, even if an LP is not available, and even if the student’s initial clinical assessment or psychiatric evaluation does not contain an order to restrain. Staff are so authorized in order to maintain safe conditions for students and staff.
6. Supervisor and LP Notification; LP Orders for Continuation of Restraint
If a restraint is initiated in response to an emergent and immediate danger presented by a student, the Supervisor or Assistant Supervisor on duty must be contacted as soon as possible and no longer within 5 minutes.
If the restraint must be continued for up to 20 minutes, the restraint then constitutes an extended restraint, and a Licensed Practitioner must be contacted, preferably by the supervisor/assistant supervisor. The LP will assess the situation to determine whether the physical restraint continues to be necessary and proper. If the LP determines that the restraint continues to be necessary and proper, he/she will order the restraint or the continuation of the restraint.
If the LP determines that continuation of the restraint is not necessary and proper, he/she will order the restraint to be discontinued immediately.
If, for any reason, a Licensed Practitioner cannot be reached at or near to the 20 minute point of the physical intervention, an LP must be contacted within 1 hour of the initiation of the restraint to authorize the restraint, and, if necessary, to authorize the continuation of the restraint. As noted, the Licensed Practitioner has the authority to immediately end the restraint should he/she find that the restraint, or its continuation, is unsafe, is not warranted, or that proper procedures are not being followed.
7. Time Limits on LP Orders to Restrain

 

LP Orders to restrain are time limited and are designated as such in the restraint order.
The restraint order for children under the age of 9 is limited to 1 hour.
For children age 9 to 17, the order is limited to 2 hours.
For children aged age 18 and older, the order is limited to 4 hours.

 

8. In-Person Evaluation of the Student

 

An LP will conduct an in-person evaluation of the student in restraint
• within 2 hours of the initiation of the restraint for children age 17 and under;
• within 4 hours of the initiation of the restraint for students age 18 and older.
During the evaluation the LP will work with the student and the staff to identify ways to help the student regain self-control, review alternative intervention approaches, and to provide a new order to restrain, if necessary.
If the student is no longer being restrained when the original verbal order expires, an LP will conduct an in-person evaluation of the student within 24 hours of the initiation of the restraint.

 

9. In-Person Reevaluations; Continuation of LP Orders to Restrain

 

If, for safety purposes, the restraint must extend beyond the original order, the student must receive an in-person reevaluation by a Licensed Practitioner before the LP authorizes the continuation of the restraint. Authorization to continue restraint is based on the student’s continued behavior that demonstrates the need for the restraint to be continued for safety purposes.
Reevaluation of the student in restraint will be conducted:
• every hour for students under the age of 9;
• every 2 hours for students aged 9 to 17;
• every 4 hours for students age 18 and older.
D. Conducting the Restraint; Maintaining Safety

 

1. Maintaining Safe and Appropriate Conditions

 

Hillcrest Educational Centers does not endorse the use of single person restraints. At least two staff members should be involved in restraining a student to maximize control, to maximize the ability to monitor the student for signs of distress and to ensure safety for all. When possible, the student should be restrained on a non-abrasive surface. Staff need to assess the student’s surroundings for safety. Staff must also try to ensure that the area in which the restraint is conducted is clean and that all issues of modesty, visibility to other children and maintaining a comfortable body temperature are addressed.
The restraint must be conducted utilizing the least restrictive technique possible and in as non-threatening and therapeutic a manner as possible, and as gently as possible while still maintaining control over the student’s movement. Care must be taken not to place undue pressure or weight on the student’s joints, the chest, the back, or abdomen. At no time shall the nose or the mouth of the student be obstructed. Only the protective and physical intervention techniques of the current crisis prevention and intervention model may be employed by staff.

 

2. Monitoring

The monitoring of a restraint for physical distress or injury is a conducted in order to ensure the student’s physical safety. Monitoring is conducted by a staff member who is directly involved in conducting the hold or restraint, and who is trained and competent to monitor restraints.
Effective monitoring requires that at least one staff involved in the restraint be able to see the student‘s face at all times during the restraint. Monitoring is conducted as an interim safety measure until a staff member outside of the restraint is able to function as the assessor of the restraint.

 

3. Continuous Assessment of Restraints

Continuous assessment of a restraint, like monitoring, is conducted in order to ensure the student’s safety and to minimize potential harm to a student. Continuous assessment is conducted as soon as possible after the initiation of the restraint and is continues until the restraint is discontinued. Continuous assessment of the restraint is performed by a trained and competent staff. Continuous assessment is conducted by a staff member who is not taking part in the restraint of the student. The assessor must be able to see the student’s face at all times during the restraint. The staff conducting the continuous assessment will assess, as indicated, the type of restraint being employed; signs of injury to student or involved staff; hydration; movement of the extremities; breathing; hygiene and elimination; physical and psychological status and comfort; and readiness for discontinuation of the restraint. The staff conducting the continuous assessment will also try to assist the student in meeting the behavioral criteria for the discontinuation of restraint and restoring safe conditions.
All Hillcrest Educational Centers staff that provide direct care or services to students must receive training in and demonstrate competence in conducting continuous assessments.
4. Discontinuing the Restraint

Restraint is discontinued as soon as it is safe to do so, when the student is no longer an immediate danger to self or others; if the student indicates that he or she cannot breath; or if the student is observed to be in severe distress, such as having difficulty breathing, or sustained or prolonged crying or coughing.
E. Disengaging and Processing
1. Disengaging

 

The procedure for disengaging from any physical intervention includes formally checking the student‘s physical condition.
a) Staff will clearly and directly ask the student if he/she has been injured or is experiencing any physical pain/discomfort.
b) Staff will also observe the student’s facial expressions, movement, and gait for signs of physical injury or pain/discomfort.
A restraint will be discontinued immediately if the student has visible bleeding, fluid coming out of their ears, seizure activity, vomiting, breathing difficulty, fracture or dislocation, is in an unconscious or unresponsive state, or any other indication of a medical emergency. If at any time during restraint a student states that they cannot breathe, staff will immediately discontinue the restraint.
2. Processing

 

Hillcrest Educational Centers endorses the use of processing aimed at understanding the incident, identifying supports that the student needs, identifying and practicing skills for the future, and making relationship repairs needed. The Skills for Life Treatment model and the Therapeutic Crisis Intervention model provide opportunities for processing that includes, but is not limited to the Life Space Interview, Situational Analysis, Collaborative Problem Solving, Skill Coaching Exercises, and the Student Incident Comment Form.
For students who are non-verbal or severely developmentally delayed verbal processing may not occur. Using behavioral momentum, returning the child to the previous activity, or offering alternative activities in accordance with ABA guidelines may be used as a means of addressing problematic behavior without re-escalating the student or providing inappropriate reinforcement for the problematic behavior.
3. Life Space Interview

 

When the student has calmed and returned to baseline behavior, the staff involved in the incident will engage the student in the Life Space Interview process. This is used to support the student in processing through the incident and exploring their reactions to difficult situations as a way to help student gain insight into their feeling and behaviors. The Life Space Interview focuses the student on developing self-regulation skills. Staff and student work collaboratively through the Life Space Interview to connect the student’s feeling with behaviors, to strategies ways to respond to challenging situations in the future and to practice skills.
4. Student Incident Comment Form

 

Within 24 hours of a restraint, the incident will be thoroughly processed with the student through the use of the Student Incident Comment Form. During the processing, the student will be offered the opportunity to provide feedback and or register concerns in writing about the incident and the way it was managed, including but not limited to the restraint itself.
If the student chooses to provide such feedback or register concerns, he/she will do so in writing on a Student Incident Comment Form that will be attached to the original restraint report form. If the student is unable to write their concerns in a coherent or legible manner, a staff member can assist them in scribing the student’s comments on the form. If a student refuses to complete a Student Incident Comment form, a second attempt must be made by a supervisor to encourage the student to complete the form. The staff assisting the student in completing the Student Incident Comment Form may not be the staff member involved in the restraint that occurred in the incident.
Addressing the questions on the Student Incident Comment Form directly may not be possible in the case of severely developmentally delayed students. The forms will be completed, whenever possible, congruent with the student’s ability to process the content of the form.
5. Debriefing

 

Hillcrest believes that debriefing incidents is an important measure to gain insight into the cause of the incident and to identify prevention strategies to reduce future occurrences. Debriefings are conducted by supervisors and ideally should be conducted with individual staff member, but may also be conducted with groups of staff members. Debriefings serve as a post crisis response in which staff can assess their response to an incident and explore ways that they can improve their response and minimize frequency of behavioral crisis and the use of restraints.
Debriefings must be conducted for the following:
a) Any floor restraint.
b) Any restraint lasting 20 minutes or more (extended restraint)
c) Any intervention resulting in injury to student or staff.
d) Any critical incident including, but not limited to:
e) AWOL
f) Sexually intrusive behavior
g) Fire-related incidents
h) Major property destruction
i) Serious self-harm behaviors/statements
j) Any other significant event a supervisor or administrator deems appropriate.

 

All debriefings will be kept on file at a central location on campus so they can be tracked for type, frequency and result, and so they may be readily available for reference. Administrators must oversee debriefing to monitor volume, quality, progress, patterns of concerns, style of supervision, etc. IOP committees will utilize data from debriefing tracking to assess its overall effectiveness and impact on treatment and performance.
Debriefing offers us a unique opportunity to learn from negative behaviors or unsafe events, and if done properly, provides staff with a greater sense of insight, skill, and support. In essence, the benefits of debriefing improve our ability to help students and generally create a safer, calmer treatment environment.

If the Program Direction directly participated in the restraint, a duly qualified individual designated by the Execustive Director shall lead the review team’s discussion. The Program Director shall ensure that a record of each individual student review is maintained and made available for review by the Department or the parent, upon request.

 

F. Documenting Restraints

 

1. Restraint Reports

 

Physical Restraints are documented via written report on an approved Hillcrest . The contents of report, required by 603 CMR 46.06(2) and (3), shall include:

  • The name of the student; the names and job titles of the staff who administered the restraint , and observers, if any; the date of the restraint; the time the restraint began and ended; and the name of the Program Director or designee who was verbally informed following the restraint; and, as applicable, the name of the LP who approved continuation of the restraint beyond 20 minutes pursuant to 603 CMR 46.05(5)(c).
  • A description of the activity in which the restrained student and other students and staff in the same room or vicinity were engaged immediately preceding the use of physical restraint; the behavior that prompted the restraint; the efforts made to prevent escalation of behavior, including the specific de-escalation strategies used; alternatives to restraint that were attempted; and the justification for initiating physical restraint.
  • A description of the administration of the restraint including the holds used and reasons such holds were necessary; the students behavior and reactions during the restraint; how the restraint ended; and documentation of injury to the student and/or staff, if any, during the restraint and any medical care provided.
  • Information regarding any further action(s) that the school has taken or may take, including any consequences that may be imposed on the student.

A restraint under 20 minutes must be documented by the use of a Restraint Report Form by the staff member who initiated the restraint. Extended restraints (20 minutes or more) must be documented by the use of an Extended Restraint Report Form by the staff member who initiated the restraint. Restraint report forms contain the following information:

  • Student name
  • Name and title of all staff involved
  • Name and title of all observers, if any
  • Date of the Restraint
  • Time the restraint began and ended
  • Total number of minutes  in restraint
  • Name of the Program Director, or designee, who was verbally informed following the restraint
  • Name of the LP who approved continuation of restraint beyond 20 minutes and name of staff receiving the order for extended restraint
  • Specific location
  • A description of the activity in which the restrained student and other students and staff in the same room or vicinity were engaged immediately preceding the use of physical restraint
  • The behavior that prompted the restraint
  • The efforts made to prevent escalation of behavior, including the specific de-escalation strategies used; alternatives to restraint that were attempted
  • Justification for initiating the physical restraint
  • Description of the administration of the restraint including the holds used and reasons such holds were necessary
  • The student’s behavior and reactions during the restraint
  • How the restraint ended
  • Documentation of injury to the student and/or staff, if any, during the restraint and any medical care provided
  • Information/description regarding any further action(s) that the school may take, including any consequences that may be imposed on the student. (e.g. processing)
  • Indication of completion of staff and student debriefing
  • Documentation of the continuous assessments of a restraint. If the restraint is continued for more than 2 hours, an additional PI form must be attached for documentation of the assessments.
  • Information regarding opportunities for the student’s parents to discuss with school officials the administration of the restraint, any consequences that may be imposed on the student, and any other related matter.

The Program Director, or designee, shall maintain an on-going record of all reported instances of physical restraint which shall be made available for review by the parent or the Department, upon request.

Each Hillcrest program site maintains data on the use of all physical interventions on computer software designed by Hillcrest’s Information Services Department. This data describes the use of restraints by student, staff member, and time of day.

2. Monitoring for Multiple Restraints

 

The Program Director, or designee, shall conduct a weekly review of restraint data to identify individual students who have been restrained multiple times during the week. If such students are identified, the Program Director, or designee, shall convene one or more review teams as they deem appropriate to assess each student’s progress and needs. The assessment shall include at least the following:

  • review and discussion of the written reports submitted in accordance with 603 CMR 46.06 and any comments provided by the student and parent about such reports and the use of the restraint;
  • analysis of the circumstances leading up to each restraint, including factors such as time of day, day of the week, antecedent events, and individuals involved;
  • consideration of factors that may have contributed to escalation of behaviors, consideration of alternatives to restraint, including de-escalation techniques and possible interventions, and such other strategies and decisions as appropriate, with the goal of reducing or eliminating the use of restraint in the future;
  • agreement on a written plan of action by the program.

The Program Director, or designee, shall conduct a monthly review of school-wide restraint data. This review shall consider patterns of use of restraints by similarities in the time of day, day of the week, or individuals involved; the number and duration of physical restraints school-wide and for individual students; the duration of restraints; and the number and type of injuries, if any, resulting from the use of restraint. The Program Director, or designee, shall determine whether it is necessary or appropriate to modify the school’s restraint prevention and management policy, conduct additional staff training on restraint reduction/prevention strategies, such as training on positive behavioral interventions and supports, or take such other action as necessary or appropriate to reduce or eliminate restraints.

 

On an ongoing basis, each program will identify a designee to monitor student restraints and determine which students have required 5 or more restraints in the last 7 day review period. If a student has required 5 or more separate instances of physical restraint during seven (7) consecutive days, the program designee will alert the program administrators. The administrators, along with other members of the treatment team as possible, will conduct a clinical and behavioral review of the student’s needs in order to determine whether the student’s treatment plan should be altered, and/or whether a Special Team meeting is indicated. The program designee will be responsible for inviting the student’s parent/guardian to this review. The results of this review, and any such changes in the treatment plan, must be documented in the case record accordingly.

 

Annual Restraint Data is submitted to DESE through WBMS.

 

3. Parent/Guardian Notification of Restraint

 

The Program Director, or designee, will make reasonable efforts to verbally inform the student’s parent/guardian of the restraint within 24 hours of the even and, within three working school days, shall notify the parent/guardian by written report sent either to an email address provided by the parent/guardian for communication about the student, or by regular mail postmarked no later than three school working days. If the school/program customarily provides a parent/guardian of a student with report cards and other necessary school-related information in a language other than English, the written restraint report shall be provided to the parent/guardian in that same language. The Program Director, or designee, shall provide the student and/or the parent/guardian an opportunity to comment on the use of the restraint and on information in the written report.

 

4. Notification of Injury From Restraint

 

The Director of Quality Assurance, Program Director, or designee, shall report all restraint-related injuries to the Department. When a physical restraint has resulted in an injury to a student or program staff member, the program shall send a copy of the written report required by 603 CMR 46.06(4) to the Department postmarked no later than three school working days of the administration of the restraint. The program shall also send the Department a copy of the record of physical restraints maintained by the Program Director, or designee, pursuant to 603 CMR 46.06(2) for the 30-day period prior to the date of the reported restraint. The Department shall determine if additional  action by the program is warranted and, if so, shall notify the program of any required actions within 30 calendar days of receipt of the required written report(s).