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CHAPTER 42
MECHANICAL RESTRAINTS AND SAFEGUARDING
EQUIPMENT
CHAPTER TABLE OF CONTENTS
SUBCHAPTER 1. GENERAL PROVISIONS
10:42-1.1 Purpose
10:42-1.2 Scope
10:42-1.3 Definitions
10:42-1.4 General requirement
SUBCHAPTER 2. SAFEGUARDING EQUIPMENT AND MECHANICAL RESTRAINTS
10:42-2.1 Use of safeguarding equipment
10:42-2.2 Mechanical restraints
SUBCHAPTER 3. APPLICATION AND IMPLEMENTATION
10:42-3.1 Application to use mechanical restraint
10:42-1.2 Implementation standard: development centers and licensed
private residential facilities
10:42-3.3 Implementation standards: community programs for the
developmentally disabled
SUBCHAPTER 4. MEDICAL/DENTAL EVALUATIONS, EXAMINATIONS OR
TREATMENT
10:42-4.1 Use of mechanical restraint for medical/dental evaluations,
examinations or treatment
SUBCHAPTER 1. GENERAL PROVISIONS
10:42-1.1 Purpose
The purpose of this chapter is to detail the policies and procedures
for the utilization of safeguarding equipment and mechanical restraints.
10:42-1.2 Scope
This chapter applies to components of the Division of Developmental
Disabilities, as well as providers regulated by or under contract with the
Division.
10:42-1.3 Definitions
For the purpose of this chapter, the following
terms shall have the meaning defined herein:
"Chief executive officer" (CEO) means the person
having administrative authority over, and responsibility for, a
State-operated developmental center or a private
licensed facility for persons with developmental disabilities under N.J.A.C.
10:47.
"Continual observation" means that the person in
mechanical restraint can be seen by a staff member at all times.
"Emergency procedures" means the brief use of
procedures to control severely aggressive or destructive behaviors that
place the individual or others in imminent danger or physical harm.
"Highly restrictive mechanical restraint" means
restraints whose use is considered to be intrusive, and can restrict
circulation, breathing or render an individual vulnerable to other persons
in the immediate area. Highly restrictive mechanical restraints include,
but are not limited to: a camisole, wrist cuff, ankle cuff, papoose boards,
restraint chairs and standing boxes.
"Human Rights Committee" means a group comprised
of professionals, individuals served, advocates, and/or interested
individuals from the community at large who function as an advisory body to
the chief executive officer, executive director, regional administrator, or
superintendent on issues directly or indirectly affecting the rights of
individuals served by the Division.
"Individual Habilitation Plan" (IHP) (see N.J.S.A.
30:6D-10 et seq.) means a written plan of intervention and action that is
developed by the interdisciplinary team. It specifies both the prioritized
goals and objectives being pursued by each individual and the steps being
taken to achieve them. It may identify a continuum of skill development
that outlines progressive steps and the anticipated outcomes of services.
The IHP is a single plan that encompasses all relevant components, such as
an education plan, a behavior modification plan, a program plan, a
rehabilitation plan, a treatment plan and a health care plan. The
complexity of the IHP will vary according to the needs, capabilities and
desires of the person. In most instances, the IHP shall address all major
needs identified. The major needs shall be prioritized. For an individual
who makes only specific service requests, the IHP shall be a service plan
which addresses only those specific requests.
"Informed consent" means a formal expression, oral
or written, of agreement with a proposed course of action by an individual
who has the capacity, the information and the ability to render voluntary
agreement on his or her own behalf or on behalf of another.
"Interdisciplinary Team" (IDT) means an
individually constituted group responsible for the development of a single,
integrated IHP. The team shall consist of the individual receiving
services; the legal guardian, the parents or family member (if the adult
desires that the parent or family member be present); those persons who
work most directly with the individual served; and professionals and
representatives of service areas who are relevant to the identification of
the individual's needs and the design and evaluation of programs to meet
them.
"Mechanical restraint" means the application of a
device which restricts freedom or movement either partially or totally.
These devices include, but are not limited to: bedside rails, mitts,
jumpsuits, arm splints, vests, helmets and body harnesses. The use of domed
or enclosed cribs shall be prohibited.
"Physical distress" means the individual is
exhibiting one or more of the following: difficulty breathing; choking;
vomiting; bleeding; fainting; unconsciousness; discoloration; swelling
at points of restraint; appearance of pain; cold extremities or similar
manifestations.
"Qualified mental retardation professional" (QMRP)
means a person who has at least one year of experience in working with
persons with developmental disabilities and is one of the following:
1. A doctor of medicine or osteopathy;
2. A registered nurse;
3. A professional program staff person who is
licensed, certified or registered, as applicable. If the professional
program staff do not fall under the jurisdiction of State licensure,
certification or registration requirements, he or she shall meet the
following qualifications:
i. To be designated as an occupational
therapist, an individual shall be eligible for certification as an
occupational therapist by the American Occupational Therapy Association or
another comparable body;
ii. To be eligible as an occupational therapy
assistant, an individual shall be eligible for certification as a certified
occupational therapy assistant by the American Occupational Therapy
Association or other comparable body;
iii. To be eligible as a physical therapist, the
individual shall be eligible for certification as a physical therapist by
the American Physical Therapy Association or other comparable body.
iv. To be eligible as a physical therapy
assistant, an individual shall be eligible for registration by the American
Physical Therapy Association or be a graduate of a two-year college level
program approved by the American Physical Therapy Association or other
comparable body;
v. To be
designated as a psychologist, an individual shall have at least a master's
degree in psychology from an accredited school;
vi. To be designated as a social worker, an
individual shall:
(1) Hold a graduate degree from a school of
social work accredited or approved by the Council on Social Work Education
or another comparable body; or
(2) Hold a Bachelor of Social Work degree from a
college or university accredited or approved by the Council on Social Work
Education or another comparable body;
vii. To be designated as a speech language
pathologist or audiologist, an individual shall:
(1) Be eligible for a certificate of clinical
competence in speech language pathology or audiology granted by the American
Speech Language Hearing Association or other comparable body; or
(2) Meet the educational requirements for
certification and be in the process of accumulating the supervised
experience required for certification;
viii. To be designated as a professional
recreation staff, an individual shall have a bachelor degree in recreation
or in a specialty area such as art, dance, music or physical education;
ix. To be designated as a professional dietician
or nutritionist, an individual shall be eligible for registration by the
American Dietetics Association;
x. To be designated as a human services
professional, an individual shall have at least a bachelor degree in a human
services field, including, but not limited to, sociology, special education,
rehabilitation, counseling or psychology.
"Safeguarding equipment" means devices which
restrict movement used to provide support for the achievement of functional
body position or proper balance; devices used for specific medical, dental
or surgical treatment; and devices to protect the individual from symptoms
of existing medical conditions, including, but not limited to, seizures,
ataxia and involuntary self abuse.
"Unusual incident" means an event involving an
individual served by the Division or employee of the Division or an agency
under contract with or regulated by the Division, involving indications or
allegations of criminal actions, injury, negligence, exploitation, abuse,
clinical mismanagement or medical malpractice; a major unforeseen event, for
example, serious fire, explosion, power failure, that presents a significant
danger to the safety or well being of individuals served and/or employees;
or a newsworthy incident. In this chapter, the term "incident" shall refer
to an unusual incident.
10:42-1.4 General requirements
(a) The Division of Developmental
Disabilities recognizes that acceptable behavior in children and adults
with developmental disabilities is fostered and maintained by a
stimulating environment, participation in activities that encourage
development of new skills and support from the people with whom they come
into contact. The Division is committed to providing a supportive
environment to persons with developmental disabilities. However, the
Division also recognizes that, even in a supportive environment, some
individuals will exhibit aggressive, destructive or self-injurious
behaviors. When such behaviors present a danger to the individual himself
or herself or others, action must be taken to help the individual control
himself or herself, or, if that is not possible to control the individual.
If the individual exhibits these problem behaviors on a regular basis, a
professionally designed program (such as a medical intervention or
behavior modification) shall be applied to change these behaviors. When
the individual exhibits a dangerous behavior that has not been previously
observed or reported, emergency measures must be available to assist them
in protecting the individual or others. Among the emergency measures that
are used in such situations are mechanical restraints. Some of the devices
used as mechanical restraints may also be used to help an individual
achieve functional body alignment or to protect the individual from harm.
In some instances, only the intended use of the device will determine
whether it is a mechanical restraint or a piece of safeguarding equipment.
(b) Devices
such as bed rails, mitts, jumpsuits, arm splints, vest, helmets and body
harnesses may be used as either a mechanical restraint for control purposes
or safeguarding equipment, depending upon circumstances. For example, a
helmet used to prevent injury due to seizures is a safeguarding device. Use
of a helmet to prevent injury due to self-injurious behavior is for control
purposes.
(c) Primary
reliance on punishment, physical or mechanical restraints or aversive
techniques to decrease undesirable behavior is contrary to Division policy.
Mechanical restraints for control purposes are considered to be appropriate
only when absolutely necessary and their use shall be minimized in favor of
other, more positive interventions.
(d) When
highly restrictive mechanical restraints are in use, continual observation
by staff is required to recognize obvious signs of physical distress.
(e) All devices
shall be applied only by staff trained in their use and applications.
(f) The need
for the particular device to be used as safeguarding equipment or for
behavioral intervention shall be documented in the
Individual Habilitation Plan (IHP) and re-evaluated no less than annually as
a part of the IHP review or as specified by the Interdisciplinary Team in
the IHP.
(g) Only
commercially produced devices shall be employed for control purposes. If a
special device must be developed, the need for the device shall be:
1. Documented
in the IHP;
2. Approved by
the Department's Chief Medical Consultant;
3. Approved by
the appropriate Human Rights Committee; and
4. Approved by
the Division Director.
(h) All
safeguarding equipment shall be prescribed by a licensed physician. With
regard to dental matters, the safeguarding equipment shall be prescribed by
a dentist.
(i) Restraints
may be used on a temporary basis to conduct medical and dental evaluations,
examinations or treatments when the individual's behavior prevents the
evaluation, examination or treatment.
(j) Mechanical
restraints shall be inspected prior to each use to ensure that they remain
in good repair and free from tears or protrusions which may cause injury.
(k) The
Division of Developmental Disabilities may require a service provider to
terminate restraint usage for an individual if any requirements of this
chapter are violated.
SUBCHAPTER 2. SAFEGUARDING EQUIPMENT AND MECHANICAL RESTRAINTS
10:42-2.1 Use
of safeguarding equipment
(a)
The use of safeguarding equipment shall be initiated on the prescription
of a physician.
(b) A
physician shall document in the client record the need for safeguarding
equipment and the specific device to be applied. That prescription shall
indicate the specific medical condition for which the safeguarding equipment
is to be used and the length of time permitted for its use. The
prescription shall be included in the client record.
(c) If the
equipment is used to prevent accidental self-injury, the physician shall
document the specific medical condition which warrants its use. The
equipment is to be used to address a specific symptom of the individuals
medical condition which is not likely to be changed through behavior
modification.
(d) Once the
physician has documented the need for safeguarding equipment, the need shall
be reviewed by the individual's IDT. If the use of the safeguarding
equipment is consistent with the goals and objectives in the individual's
IHP and can be implemented, the use of the safeguarding equipment shall be
included in the IHP.
(e) If the use
of the safeguarding device cannot be integrated into the IHP, the IDT shall
meet to revise the plan to provide for the individual's safety and
habilitation needs. The IDT shall meet within 10 working days from the
initial application for a safeguarding device.
(f) The need
for safeguarding equipment shall be reviewed as part of the IHP no less than
annually.
(g) The
continued need for a safeguarding device shall be authorized by a physician
in the client record at least annually.
10:42-2.2 Mechanical restraints
(a)
Mechanical restraints may be utilized only as follows:
1. As an
emergency measure to control a person in order to protect him/herself or
others from harm;
2. As part of
an approved behavior modification program utilizing aversive techniques to
attempt to change a targeted behavior;
3. As a
safeguarding device to protect the individual from accidental self-injury;
or
4. As a
control device for medical, surgical and dental examinations.
(b) A facility
or service provider may implement a program of mechanical restraint only
with specific authorization of the Director, Division of Developmental
Disabilities.
(c) Mechanical
restraints shall not be used as punishment (retribution), for the
convenience of staff, or as a substitute for programming.
(d) The
individual shall be immediately released if he or she appears to be in
physical distress.
(e) The
individual must be placed in the least restrictive form of mechanical
restraint unless clinical evidence to justify the use of a more restrictive
technique is available.
(f) Only
personnel who have successfully completed a training program approved by the
Division of Developmental Disabilities shall be permitted to apply, monitor
and release mechanical restraints.
(g) Whenever
an individual exhibits serious assaultive, self-injurious or destructive
behavior, controllable only by use of mechanical restraint, the
interdisciplinary team shall meet to identify possible causes and develop
strategies to address the maladaptive behavior.
SUBCHAPTER 3. APPLICATION AND IMPLEMENTATION
10.42-3.1 Application to use mechanical restraint
(a) Each facility
or service provider requesting approval to utilize mechanical restraints
shall submit to the Director, Division of Developmental Disabilities,
comprehensive written procedures governing the use of restraint.
(b) The
procedure submitted shall include the following:
1. A statement
specifically identifying the forms of mechanical restraint to be used and
the number of trained staff that shall be available to apply restraints;
2. Criteria
for use of mechanical restraint;
3.
Instructions for the application of each type of restraint;
4. Precautions
for the use of mechanical restraint including certification by a physician
that the use of restraint is not medically contra-indicated for the
individual;
5.
Recordkeeping and review requirements; and
6. A
curriculum for training staff which shall include, but not be limited to,
training in the proper use and application of each form of mechanical
restraint to be employed as well as the recognition of the signs of physical
distress.
10:42-3.2 1 Implementation standard: development
centers/licensed private residential facilities
(a) Following
approval by the Director, Division of Developmental Disabilities, for use
of mechanical restraint, the following standards shall apply:
1. Prior to
the initial restraint authorization, a physician must certify that the
technique to be employed is not medically contraindicated for the
individual.
2. In an emergency situation, the superintendent, chief
executive officer (CEO) or his or her designee shall be responsible for
authorizing the use of restraint. The authorized agent must be a qualified
mental retardation professional (QMRP) as defined in 42 CFR 483.430(a) and
this chapter.
3. The CEO
shall identify those QMRPs who are responsible to authorize the use of
restraint.
4. As soon as
possible, but in less than 24 hours, a physician must review and countersign
each "emergency" restraint order.
5. An
emergency restraint order shall be effective for not more than 12
consecutive hours. If a new order is issued, all authorization shall be
renewed.
6. Restraint
orders shall include documentation of the type of mechanical restraint
authorized, the length of time to be applied, the reason for restraint, and
any special instruction. Each restraint order must be signed and dated by
the authorizing agent.
7. Individuals
placed in highly restrictive forms of mechanical restraint shall be under
continual observation by staff trained to recognize signs of physical
distress.
8. While in a
mechanical restraint, documentation of a physical check by a staff member
every 15 minutes is required. The check shall document the following:
i. Whether
the continued use of the restraint is necessary; and
ii. Whether
the restraint is applied in accordance with principles of good body
alignment, a concern for circulation and allowance for change of position.
9. The
individual shall be released from restraint for a period of not less than 10
minutes during each hour of restraint. One limb may be released at a time
during the 10-minute period if the person cannot be completely released.
10. The use of
jumpsuits or open-faced helmets does not require 15-minute checks. The
individual does not have to be removed from the restraint for a 10-minute
period during each hour since it does not restrict range of motion.
11. The
individual's personal hygiene and nutritional needs shall be met while in
restraint.
12. If a crib
is used as a safeguarding device, documentation of 15-minute checks shall
not be required. If a crib is used for control purposes, checks shall be
required. It is not necessary to remove the individual from a crib for 10
minutes during each hour of use if the crib is used for sleeping.
13. The
nature, reasons for and notation of each staff check shall be recorded in
the client record.
14. Whenever
an individual exhibits serious assaultive self-injurious or destructive
behavior controlled by use of mechanical restraints, a special meeting of
the IDT must be held to review current programming and alternatives. If
the recurrence of the behavior may be anticipated, a behavior plan shall be
developed.
15. An unusual incident report shall
be completed.
10:42-3.3 Implementation standards: community programs
for the developmentally disabled
(a) In
community programs, the utilization of mechanical restraint shall be
considered only for those special programs adequately staffed by trained
professional personnel and serving individuals who present a danger to
himself or herself or others.
(b) Following
approval of a mechanical restraint program by the Director, Division of
Developmental Disabilities, the following shall
apply:
1. Only a
licensed psychologist or physician may authorize each use of mechanical
restraint.
2. Prior to or
at the time of the initial authorization, a physician must certify that the
technique to be employed is not medically contra-indicated for the
individual.
3. Whenever
possible, the restraint order shall be immediately signed by the licensed
psychologist or physician. However, the use of mechanical restraint may be
authorized over the telephone by the licensed psychologist or physician in
accordance with the following:
i. Such
approval is strictly temporary and the restraint order shall be reviewed and
signed by the licensed psychologist or physician as soon as possible but
at least within 12 hours of its application; and
ii. The
specific circumstances necessitating approval over the telephone shall be
part of the client record and include the name of the party requesting or
authorizing the restraint.
4. Restraint
orders shall be effective for not more than 12 consecutive hours. If a new
order is issued, all authorization shall be renewed.
5. Restraint
orders shall include documentation of the type of mechanical restraint
authorized, the length of time to be applied, the reason for restraint, and
any special instruction for utilizing the restraint. Each restraint order
must be signed and dated by the licensed psychologist or physician.
6. Individuals
placed in highly restrictive forms of mechanical restraints shall be under
continual observation by staff trained to recognize signs of physical
distress.
7. While in
mechanical restraint the individual shall be checked by a staff member every
15 minutes. The check shall document the following:
i. Whether the continued use of the restraint is necessary;
and
ii. Whether
the restraint is applied in accordance with principles of good body
alignment, a concern for circulation and allowance for change of position.
8. The
individual shall be released from restraint for a period of not less than 10
minutes during each hour of restraint. One limb may be released at a time
for a 10-minute period if the person cannot be completely released.
9. The use of
jumpsuits or open faced helmets do not require 15-minute checks. The
individual does not have to be removed from the restraint for a 10-minute
period during each hour of use since it does not restrict range of motion.
10. The
nature, reasons for and notation of each staff check shall be recorded in
the client record.
11. The
individual's personal hygiene and nutritional needs shall be met while in
restraint.
12. The
service provider shall forward a report of the unusual incident to the
Regional Assistant Director.
13. Whenever
an individual exhibits serious assaultive, self-injurious or destructive
behavior controlled by the use of mechanical restraints, a special meeting
of the IDT must be held to review programming and alternatives. If a
recurrence of the behavior is anticipated, a behavior plan shall be
developed. The IDT shall forward the results of their review to the
regional Human Rights Committee within 15 working days.
14. The
Regional Human Rights Committee shall review the pertinent circumstance
surrounding the utilization of each application of emergency mechanical
restraints. The results of this review shall be forwarded to the Regional
Assistant Director, appropriate Regional Administrator, and the Office of
Licensing and Inspections within 10 days of the review by the Human Rights
Committee.
SUBCHAPTER 4. MEDICAL/DENTAL EVALUATIONS,
EXAMINATIONS OR TREATMENT
10:42-4.1 Use of mechanical restraint for
medical/dental evaluations, examinations or treatment
(a) The physician/dentist may use or
direct the use of restraint to accomplish a needed evaluation, examination
or treatment. Such use shall be documented in the client record.
(b) Informed
consent shall be required unless an emergency exists.
(c) In the
judgment of the physician/dentist, when there is an emergency he or she may
use or direct the use of restraints to accomplish a needed evaluation,
examination or treatment. Such use shall be documented in the client
record.
(d) Restraints
shall be used under the continuous observation of the physician/dentist or
his/her designee. The individual shall be released upon completion of the
necessary procedures.
(e) At no time
shall the individual be permitted to remain in restraints for the
convenience of staff including pre- and post-treatment.
