EMERGENCY USE OF MANUAL RESTRAINTS

In addition to the behavior intervention policy and procedure, the following procedures are followed if and when it is necessary to perform the emergency use of a manual restraint.

Responding to Escalating Disruptive Behavior

When a person begins to engage in escalating disruptive behavior and it becomes apparent that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of others if not redirected, implement the following steps:

1. Attempt de-escalation techniques. 
   • De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural).
2. If applicable, review the use of the person’s PRN use medication to address target mental health symptoms.
3. If the person’s behavior continues to be disruptive, ask that the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity  – this is a voluntary time out.
4.  Monitor the person’s behaviors while they choose to be in a voluntary time out.
5.  When the person stops the disruptive or threatening behavior, prompt them to return to normal activities.
6.  If appropriate or possible, remove all people whose safety is threatened, from the immediate area of the threatening person.
7.  If the person continues to refuse to remove him or herself from the situation and the challenging behaviors continue or escalate, implement personal safety techniques as trained.
   • Personal Safety Techniques:

• ​Wrist release:  Place one foot slightly forward and bend knees.  Use your free hand to grasp the back of their own hand and pull up following the direction of the thumb of the restrained hand until hold is released. Then position your hand on the inside of the individual’s opposite arm and pull to a one-arm wrap around
• Bite release:  Gently apply pressure, pushing the body part being bitten into individual’s mouth making a seal.  Simultaneously using thumb and forefinger to squeeze nose and block air passage until individual opens mouth to inhale and hold is released.​
• Clothing release: Use the outside hand to stabilize the hand grabbing clothing.  Then use the inside hand to hold clothing and gently pull out of individuals grasp.
• Hair pull: Use one hand to stabilize the wrist of hand pulling hair, then use your other hand to gently peel individual’s fingers from hair
• Object removal (not to be used with dangerous items i.e. butcher knives, guns): As individual begins to attack, bend at the elbows bringing hand towards toward face, palms facing outwards as to block.  Then reach to grab object and/or wrists and attempts to peel object out of individual’s hands.
• Blocking Punches and kicks: As individual advances to kick or punch, shuffle back while simultaneously bending arms and bringing both hands in front of face, palms facing outwards.

8. If the person begins to engage in behavior that is continuous aggression, continuous self-injury, or high magnitude disruption that threatens the safety of themselves or others, emergency manual restraint may be implemented, as trained.  When implementing an emergency use of manual restraint start with the least restrictive procedure necessary to keep the individual and others safe.

• If a restraint is being implemented following a personal safety technique, following the implementation of the personal safety technique you may pull to a one-arm wrap around.

9. After implementing the manual restraint, attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety.

Mains’l will not allow the use of a manual restraint procedure with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning required under section 245D.070, subdivision 2, for recipients of basic support services; or the assessment and initial service planning required under section 245D.071, subdivision 3, for recipients of intensive support services.

Manual Restraints Allowed in Emergencies

Below is a list of each of the manual restraints trained staff are allowed to use on an emergency basis when a person’s actions pose an imminent (it is about to happen) risk of physical harm to self or others and less restrictive strategies have not achieved safety. The list includes instructions for the safe and correct implementation of those procedures.

They are listed in order of least to most restrictive:

1. Wrist Side Hug Procedure:  Standing next to the individual, using your outside hand, grasp the individual’s wrist above or below the wrist bone, making sure to position their thumb on top of your wrist.  It is important to not grasp the wrist directly as this could cause pain and potentially injury to the person. With your inside hand, closest to individual, wrap your hand around the back of the individual and grasp their triceps on the opposite side of the individuals body, making sure to keep your fingers and thumb together and not grabbing at the individual to cause bruising or pain (This is only used to move an  individual out of harm’s way)
2. Wrap Around- Bear Hug Style:  standing next to individual, staff wrap both of their arms around individual using one hand to grasp their own wrist.

Conditions for Emergency Use of Manual Restraint

Emergency use of manual restraint must meet the following conditions:

• Immediate intervention must be needed to protect the person or others from imminent risk of physical harm;
• The type of manual restraint used must be the least restrictive intervention to eliminate the immediate risk of harm and effectively achieve safety.  The manual restraint must end when the threat of harm ends.
• A manual restraint is only allowed in an emergency when a person’s behavior poses an imminent risk of physical harm to them self or others and the less restrictive strategies have not achieved safety.
• Documentation must be provided to show that positive approaches have been tried and have been unsuccessful as a condition of implementing an emergency use of manual restraint.
• The program must monitor a person’s health
• Property damage, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own, do not constitute an emergency.
• Within 24 hours of an emergency use of manual restraint, the legal representative and the case manager must receive verbal notification of the occurrence.
• The use of an emergency manual restraint has been approved in the person’s support plan.
• The employee performing the emergency use of a manual restraint has completed training and demonstrated competence in performing a manual restraint.

Restrictions When Implementing Emergency Use of Manual Restraint

Emergency use of manual restraint must not:

1.   be implemented with a child in a manner that constitutes sexual abuse, neglect, physical abuse, or mental injury;

2.   be implemented with an adult in a manner that constitutes sexual abuse, neglect, physical abuse or mental injury;

3.   be implemented in a manner that violates a person’s rights and protection;

4.   be implemented in a manner that is medically or psychologically contraindicated for a person;

5.   restrict a person’s normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, or necessary clothing;

6.   restrict a person’s normal access to any protection required by state licensing standards and federal regulations governing this program;

7.   deny a person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;

8.   be used as a substitute for adequate staffing, for the convenience of staff, as punishment, or as a consequence if the person refuses to participate in the treatment or services provided by this program;

9.   use prone restraint. “Prone restraint” means use of manual restraint that places a person in a face-down position. It does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side-lying position as quickly as possible; or

10. apply back or chest pressure while a person is in a prone position, supine (meaning a face-up) position, or side-lying position,

11. be implemented in a manner that is contraindicated for any of the person’s known medical or psychological limitations.

Monitoring Emergency Use of Manual Restraint

Mains’l must monitor a person’s health and safety during an emergency use of a manual restraint. When possible, a staff person who is not implementing the emergency use of a manual restraint must monitor the procedure. The purpose of the monitoring is to ensure the following:

1.   only manual restraints allowed in this policy are implemented;

2.   manual restraints that have been determined to be contraindicated for a person are not implemented with that person;

3.   allowed manual restraints are implemented only by staff trained in their use;

4.   the restraint is being implemented properly as required; and

5.   the mental, physical, and emotional condition of the person who is being manually restrained is being assessed and intervention is provided when necessary to maintain the person’s health and safety and prevent injury to the person, staff involved, or others involved.

Reporting Emergency Use of Manual Restraint

The staff who implemented any form of manual restraint procedure:

1. Notifies the assigned manager immediately.
2. Completes the Behavior Intervention Reporting Form (BIRF) and submits it to the manager prior to leaving the shift.
   
   • Each single incident of emergency use of manual restraint must be reported separately. A single incident is when the following conditions have been met:
     • after implementing the manual restraint, staff attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety
     • upon the attempt to release the restraint, the person’s behavior immediately re-escalates; and
     • staff must immediately re-implement the manual restraint in order to maintain safety.
3. If a PRN medication is given for target behaviors (chemical restraint) rather than for target mental health symptoms, staff completes the BIRF.
4. If 911 was called, the staff responsible at the time of the incident:

• Completes an incident report;
• Calls the on-call administrative personnel to report the incident;
• Notifies the manager, who notifies the case manager and the legal representative of the incident within 24 hours

The manager/designated coordinator:

1. Within 24 hours of an emergency use of manual restraint, the manager contacts the legal representative and the case manager to provide verbal notification of the occurrence.

• When the emergency use of manual restraint involves more than one person receiving services, the incident report made to the legal representative and the case manager must not disclose personally identifiable information about any other person unless the program has the consent of the person.

b. Within (5) working days of the behavior intervention, reviews and finalizes the Behavior Intervention Internal Review form.

Expanded Support Team Review of Emergency Use of Manual Restraint

Within 5 business days after the completion of the internal review, the manage or senior manager must consult with the expanded support team to:

1.   Discuss the incident to:

a.   define the antecedent or event that gave rise to the behavior resulting in the manual restraint;  and

b.   identify the perceived function the behavior served.

2.   Determine whether the person’s service and support plan needs to be revised to:

a.   positively and effectively help the person maintain stability; and

b.   reduce or eliminate future occurrences of manual restraint.

3.   Make the revisions to the person’s service and support plan when it is determined necessary.

The written summary of the expanded support team’ discussion and decisions will be documented on the Expanded Support Team Review Form and saved in the person’s plan file.

Internal Review of Emergency Use of Manual Restraint

a. Within 5 business days after the date of the emergency use of a manual restraint, the senior manager must complete and document an internal review of the report prepared by the staff member who implemented the emergency procedure. The internal review must include an evaluation of whether:

1.   the person’s service and support strategies need to be revised;

2.   related policies and procedures were followed;

3.   the policies and procedures were adequate;

4.   there is need for additional staff training;

5.   the reported event is similar to past events with the persons, staff, or the services involved; and

6.   there is a need for corrective action by the program to protect the health and safety of persons.

b. Based on the results of the internal review, the senior manager must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or Mains’l.

c. The corrective action plan, if any, must be implemented within 30 days of the internal review being completed

d. The original is filed in the person’s plan file and a copy is submitted to the director.

External Review and Reporting of Emergency Use of Manual Restraint

Within 5 business days after the completion of the expanded support team review, the senior manager must submit the following to DHS using the online behavior intervention reporting form which automatically routes the report to the Office of the Ombudsman for Mental Health and Developmental Disabilities:

1.   report of the emergency use of a manual restraint;

2.   the internal review and corrective action plan; and

3.   the expanded support team review written summary.

Positive Support Transition Plan

If an individual uses a positive support transition plan, the plan will be written by a Board Certified Behavior Analyst.  The plan will be written and phased out within 11 months form the date of plan implementation. The BCBA will use the DHS created and approved plan.