Emergency Safety Interventions

Purpose

Recovery Works seeks to safeguard the safety of its clients and staff, and to exemplify dignity and respect in the treatment of others with within its therapeutic community.

A safe and healthy environment is to be promoted for all; clients and staff must be protected from injury.

Policy

  1. All clients sign a written agreement to abide by the rules of Recovery Works.

  2. These rules include a prohibition against any verbally threatening or physically threating behavior towards staff or clients.

  3. Non-physical behavioral interventions are to be employed with clients who appear to be out of control.

  4. These interventions will not include any type of physical restraint, mechanical restraint, or seclusion.

  5. Every attempt should be made to verbally quiet and calm the agitated individual.

  6. If the behavior cannot be calmed with verbal measures and still poses a threat to staff and clients, the individual will be asked to leave premises by the supervisor in charge.

  7. If an individual who has been asked by the program to leave the premises refuses, 911 is called to request removal from the premises.

  8. Recovery Works maintains a 24-hour hotline to assist in the event of a crisis, 770-559-0550. (cf. 111.8.19.09.8)

  9. Medical or psychiatric emergencies are handled by calling 911.

  10. Recovery Works must have at least one staff member with a valid certificate of course completion for basic cardiopulmonary life support training.

  11. One staff member satisfying these training requirements shall be present at all times that clients are in the facility.

  12. Certificates of course completion are valid based on the time frames established by each first aid and CPR training program, not to exceed three (3) years.

  13. Documentation that identified staff members have met the first aid and cardiopulmonary resuscitation training requirement shall be kept on-file.

  14. At least one first aid kit containing materials to administer first aid must be maintained on the premises at all times.

  1. Recovery Works does not maintain or provide an emergency safety service.

  2. Medical, psychiatric, or law enforcement emergencies are handled by calling 911.

  3. Any immediate interventions by Recovery Works staff that would otherwise be necessary to prevent immediate injury are otherwise subject to the following requirements:

    1. Emergency safety interventions may be used only:

      1. By staff trained in the proper use of such interventions;

      2. When it can be reasonably anticipated from a client’s behavioral history, that a client may require the use of emergency safety interventions to keep either the client or others safe from immediate physical harm; and

      3. When less restrictive means of dealing with the injurious behavior have not proven successful or may subject the client or others to greater risk of injury.

    2. Clients who are anticipated to require such emergency safety interventions, would, by definition, require a higher level of care than that available at Recovery Works.

    3. No emergency safety intervention may use a restraint or manual hold that could impair breathing ability.

No emergency safety intervention shall be used that has been determined to be inappropriate for use on a particular client due to a documented medical or psychological condition.

  1. A copy of the program’s written policies and procedures for the use of emergency safety interventions shall be provided to and discussed with each client (as appropriate taking into account the client’s age and intellectual development) and the client's parents and/or legal guardians prior to or at the time of admission.

Emergency safety interventions policies and procedures shall include:

i. An assessment at admission and at each annual exam by the client’s physician, a physician’s assistant, or a registered nurse with advanced training working under the direction of a physician, or a public health clinic which states that there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that client.

Such assessment and documentation must be re-evaluated following any significant change in the client's medical condition.

  1. Any use of an emergency safety intervention must document:

    1. Date and description of the precipitating incident;

    2. Description of the de-escalation techniques used prior to the emergency safety intervention, if applicable;

    3. Environmental considerations;

    4. Names of staff participating in the emergency safety intervention;

    5. Any witnesses to the precipitating incident and subsequent intervention;

    6. Exact emergency safety intervention used;

    7. Documentation of the 15 minute interval visual monitoring of a client in seclusion;

(Recovery Works does not provide seclusion.)

  1. Beginning and ending time of the intervention;

  2. Outcome of the intervention;

  3. Detailed description of any injury arising from the incident or intervention; and

  4. Summary of any medical care provided.

  1. Manual holding is prohibited by any employee not trained in prevention and use of emergency safety interventions.

    1. Emergency safety interventions may be used to prevent runaways only when the client presents an imminent threat of physical harm to self or others, or as otherwise specifically specified in the individual treatment plan.

    2. Program staff shall be aware of each client’s medical and psychological conditions (e.g. obvious health issues, list of medications, history of physical abuse, etc.), as evidenced by written acknowledgement of such awareness, to ensure that any emergency safety intervention that were utilized would not pose an undue danger to the physical or mental health of the client.

    3. Clients shall not be allowed to participate in the emergency safety intervention of other clients.

    4. Immediately following the conclusion of any emergency safety intervention, and hourly thereafter for a period of at least 4 hours, where the client is with a staff member, the client’s behavior must be assessed, monitored, and documented to ensure that the client did not appear to be exhibiting any symptoms that could be associated with an injury.

    5. The emergency safety intervention program must include:

      1. Techniques for de-escalating problem behavior including client and staff debriefings;

      2. Appropriate use of emergency safety interventions;

      3. Recognizing aggressive behavior that may be related to a medical condition;

      4. Awareness of physiological impact of a restraint on the client;

      5. Recognizing signs and symptoms of positional and compression asphyxia and restraint associated cardiac arrest;

      6. Training instruction on how to monitor the breathing, verbal responsiveness, and motor control of a client who is the subject of an emergency safety intervention;

      7. Training of appropriate self-protection techniques;

      8. Recovery Works prohibitions on using manual holds, includes the prohibition of any such intervention that would potentially impair a client’s ability to breathe;

      9. Staff involved with any emergency intervention incident shall

be aware of all policies and reporting requirements; as well as understand:

  1. Alternatives to restraint;

  2. Avoiding power struggles;

  3. Escape and evasion techniques;

  4. Prohibitions for the use of restraint and seclusion;

  5. Process for public emergency services for any use or continuation of use of restraints or seclusion;

  6. Procedures to address any problematic restraints potential;

  7. Documentation requirements;

  8. Process for investigation of injuries and complaints;

  9. Monitoring physical signs of distress and obtaining medical assistance; and

  10. Legal issues.

  1. Emergency safety intervention training shall be in addition to the annual training required in 111.19.10.8b and shall be documented in the staff member’s personnel record.

  2. Any actions taken that could involve utilizing an emergency safety intervention must be recorded in the client’s case record, showing the cause for the emergency safety intervention, the emergency safety intervention used, and, if needed, approval by the clinical director, the staff member in charge of casework services, and the

physician who has responsibility for the diagnosis and treatment of the client's behavior.

  1. Consistent with section 111.8.19.09.13, Recovery.Works shall submit to the Georgia Department of Community Health electronically or by facsimile, a report, in a format acceptable to the department, within 24 hours whenever the program becomes aware of an incident which results in injury to a client requiring medical treatment beyond first aid that is received by a client as a result of or in connection with any emergency safety intervention.

    1. For any program with a licensed capacity of 20 clients or more, any 30-day period in which 3 or more instances of emergency safety interventions of a specific client occurred and/or whenever the program has had a total of 10 emergency safety interventions for all clients in care within the 30-day period; and

    2. For any program with a licensed capacity of less than 20 clients, any 30-day period in which 3 or more instances of emergency safety interventions of a specific client occurred and/or whenever the program has had a total of 5 instances for all clients in care within the 30-day period.

  2. Programs must submit a written report to the Recovery.Works clinical director on the use of any emergency safety intervention immediately after the conclusion of the intervention (and, if the client were a child or has an assigned legal guardian, it is further required that the program shall notify the client’s parents or legal guardians regarding the use of the intervention).

A copy of such report shall be maintained in the client’s file.

  1. At least once per quarter, the program, utilizing a master agency

restraint log and the client’s case record, shall review the use of all emergency safety interventions for each client and staff member, including the type of intervention used and the length of time of each use, to determine whether there was a clinical basis for the intervention, whether the use of the emergency safety intervention was warranted, whether any alternatives were considered or employed, the effectiveness of the intervention or alternative, and the need for additional training. Written documentation of all such reviews shall be maintained. Where the program identifies opportunities for improvement as a result of such reviews or otherwise, the program shall implement these changes through an effective quality improvement plan.

  1. All program staff involved in the use of emergency safety interventions shall have evidence of having satisfactorily completed a nationally recognized training program for emergency safety interventions to protect clients and others from injury, which has been approved by the Department of Community Health and taught by an appropriately certified trainer in such program.

  2. Manual Holds.

    1. Any manual hold would require at least 1 trained staff member to carry out such a hold. (Prone restraints require at least 2 trained staff members.)

    2. Emergency interventions shall not include the use of any restraint or manual hold that would potentially impair the client’s ability to breathe or has been determine d to be inappropriate for use on a particular client due to a documented medical or psychological condition.

    3. When a manual hold is used upon any client whose primary mode of communication is sign language, the client shall be permitted to have his or her hands free from restraint for brief

periods during the intervention, except when such freedom may result in physical harm to the client or others.

  1. If the use of a manual hold were to exceed 15 consecutive minutes, the clinical director or his or her designee, who possesses at least the qualifications of the clinical director and has been fully trained in the program’s emergency safety intervention plan, shall be contacted by a two-way communications device or in person and determine that the continuation of the manual hold is appropriate under the circumstances.

Documentation of any consultations and outcomes shall be maintained for each application of a manual hold that exceeds 15 minutes.

Manual holds shall not be permitted to continue if the restraint is determined to pose an undue risk to the client’s health given the client’s physical or mental condition.

  1. Any manual hold may not continue for more than 30 minutes at any one time without the consultation as specified in subparagraph (4) of this subparagraph, and under no circumstances may a manual hold be used for more than one hour total within a 24-hour period.

  2. Any use of a manual requires reconsideration for alternative treatment strategies, documentation of same, consideration of notifying the authorities or transporting the client to a hospital or mental health facility for evaluation for treatment at a higher level of care.

  3. The client’s breathing, verbal responsiveness, and motor control must be continuously monitored during any manual

hold.

Written summaries of the monitoring by a trained staff member not currently directly involved in the manual hold must be recorded every 15 minutes during the duration of any such restraint.

If only 1 trained staff member were involved in such restraint, and no other staff member were available, written summaries of the monitoring of the manual hold must be recorded as soon as is practicable, but no later than 1 hour after the conclusion of any such restraint.

  1. Seclusion.

Recovery Works does not provide psychiatric seclusion or a seclusion room.

Any client in need of seclusion would be, by definition, not appropriate for the Recovery Works program.

Any patient who may require psychiatric seclusion for safety purposes should be transported by emergency services to a hospital or other appropriate psychiatric facility.

Authority: O.C.G.A. §§ 26-5-14, 26-5-15, 26-5-16, 50-13-18.