D. Restraint and Seclusion Guidelines
Many trauma-informed care trainings promote specific strategies including self-care approaches, peer-provided services, arts programs, and comfort rooms to enhance healing and as means to avoid the use of restraint and seclusion. In Texas, the Administrative Code offers the following guidelines on restraining and secluding children in General Residential Operations and Residential Treatment Centers:
1. Restraint/Seclusion May Only Be Used:
• As last resort
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2551(a); and 40 Tex. Admin. Code § 749.2151
• After less restrictive and more positive measures have been tried and failed
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2551(a); and 40 Tex. Admin. Code § 749.2151(a)
• Only in an emergency situation
40 Tex. Admin. Code § 748.2455(a)(1)(2); 40 Tex. Admin. Code § 749.2055(a)(1)(2); 40 Tex. Admin. Code § 748.2401(5); and 40 Tex. Admin. Code § 749.2001(5)
(Definition of emergency situation)
• Where immediately necessary
40 Tex. Admin. Code § 748.43(17); 40 Tex. Admin. Code § 749.43(18) (Definition of EBI) 40 Tex. Admin. Code § 748.2401(5); and 40 Tex. Admin. Code § 749.2001(5) (Definition of emergency situation)
• To prevent imminent probable death or substantial bodily harm
40 Tex. Admin. Code § 748.43(17); 40 Tex. Admin. Code § 749.43(18) (Definition of Emergency Behavioral Intervention (EBI)); 40 Tex. Admin. Code § 748.2401(5); 40 Tex. Admin. Code § 749.2001(5) (Definition of emergency situation); 40 Tex. Admin. Code § 748.43(47); and 40 Tex. Admin. Code § 749.43(56) (Definition of substantial bodily harm)
• NEVER as punishment, retaliation, convenience, treatment, or means of compliance
40 Tex. Admin. Code § 748.2463 and 40 Tex. Admin. Code § 749.2063
2. Types of Restraints That May Be Administered with Restrictions:
• Physical restraint
40 Tex. Admin. Code § 748.2451(a)(2); 40 Tex. Admin. Code § 749.2051(a)(2); 40 Tex. Admin. Code § 748.2401(7); and 40 Tex. Admin. Code § 749.2001(7) (Definition)
• Emergency medication
40 Tex. Admin. Code § 748.2451(a)(3); 40 Tex. Admin. Code § 749.2051(a)(3); 40 Tex. Admin. Code § 748.2753 (simultaneous use with another EBI); 40 Tex. Admin. Code § 749.2233 (simultaneous use with personal restraint); 40 Tex. Admin. Code § 748.2401(4); and 40 Tex. Admin. Code § 749.2001(4) (Definition)
• Seclusion
40 Tex. Admin. Code § 748.2451(a)(4); 40 Tex. Admin. Code § 748.2651; 40 Tex. Admin. Code § 748.2401(10); 40 Tex. Admin. Code § 749.2001(10) (Definition); and 40 Tex. Admin. Code § 749.2051(b)
• Mechanical restraint
40 Tex. Admin. Code § 748.2451(a)(5); 40 Tex. Admin. Code § 748.2701; 40 Tex. Admin. Code § 748.2703; 40 Tex. Admin. Code § 748.2755 (simultaneous use with emergency medication); 40 Tex. Admin. Code§ 748.2401(6); 40 Tex. Admin. Code § 749.2001(6) (Definition); and 40 Tex. Admin. Code § 749.2051(b)
3. Restraint/Seclusion May Only Be Administered by:
• Qualified caregiver
40 Tex. Admin. Code § 748.2453 and 40 Tex. Admin. Code § 749.2053
• Trained in emergency behavior interventions
40 Tex. Admin. Code § 748.947; 40 Tex. Admin. Code § 749.947; 40 Tex. Admin. Code § 748.903; 40 Tex. Admin. Code § 749.903; 40 Tex. Admin. Code § 748.863(a); 40 Tex. Admin. Code § 749.863(a); 40 Tex. Admin. Code § 748.901; and 40 Tex. Admin. Code § 749.901
• Whose duties include the direct care, supervision, guidance, and protection of child
40 Tex. Admin. Code § 748.43(5) and 40 Tex. Admin. Code § 749.43(7)
4. A Child Must Be Released from a Restraint:
• IMMEDIATELY if an emergency health situation arises
40 Tex. Admin. Code § 748.2553(4)(A); 40 Tex. Admin. Code § 748.2553(5)(A); 40 Tex. Admin. Code § 748.2603; and 40 Tex. Admin. Code § 749.2203
• IMMEDIATELY once the danger is over
40 Tex. Admin. Code § 748.2553(2)(C) and 40 Tex. Admin. Code § 749.2153(2)(C)
• Once maximum time allowed is reached
40 Tex. Admin. Code § 748.2553(2)(E); 40 Tex. Admin. Code § 749.2153(2)(E); and 40 Tex. Admin. Code § 748.2553(4)(D)
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Type of Emergency Behavior Intervention |
The caregiver must release the child: |
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(1) Short personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; or (B) Within one minute, or sooner if the danger is over or the disruptive behavior is de-escalated. |
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(2) Personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; (B) Within one minute of the implementation of a prone or supine hold; (C) As soon as the child's behavior is no longer a danger to himself or others; (D) As soon as the medication is administered; or (E) When the maximum time allowed for personal restraint is reached. |
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(3) Emergency medication |
Not applicable. |
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(4) Seclusion |
(A) Immediately when an emergency health situation occurs during the seclusion. The caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the required behaviors; (D) When the maximum time allowed for seclusion is reached; (E) If the child falls asleep in seclusion. In this situation, the caregiver must: (i) Unlock the door; (ii) Continuously observe the child until he awakens; and (iii) Evaluate his overall well-being; or (F) If the child is receiving emergency care services: (i) As soon as the child is no longer a danger to himself or others; (ii) Upon the arrival of a medical professional; or (iii) Upon assistance from law enforcement or the fire DFPS. |
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(5) Mechanical restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the required behaviors; (D) When the maximum time allowed for mechanical restraint is reached; or (E) If the child falls asleep in the mechanical restraint. In this situation, the caregiver must release the child from the restraint and continuously observe the child until he awakens and evaluate him. |
The maximum amount of time for a restraint/seclusion:
• Physical Restraint – under the age of 9, 30 minutes; 9 or over, 1 hour
• Seclusion – <9, 1 hour; ≥9, 2 hours; < cumulative total of 2 hrs./12 hr. period
• Mechanical Restraint – <9, 30 minutes; ≥9, 1 hour; <cumulative total of 1 hr./12 hr. period
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Figure: 40 Tex. Admin. Code § 748.2801 |
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Types of Emergency Behavior Intervention |
The maximum length of time is: |
|
(1) Short personal restraint |
One minute. |
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(2) Personal restraint |
(A) For a child under nine years old, 30 minutes; (B) For a child nine years old or older, one hour; or (C) A prone or supine personal restraint hold may not exceed one minute. |
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(3) Emergency medication |
Not applicable. |
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(4) Seclusion |
(A) For a child under nine years old, one hour. (B) For a child nine years old or older, two hours. |
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(5) Mechanical restraint |
(A) For a child under nine years old, 30 minutes. (B) For a child nine years old or older, one hour. |
When restraining/secluding, a written order is required:
• By a licensed physician when administering emergency medications
40 Tex. Admin. Code § 748.2501(3) and 40 Tex. Admin. Code § 749.2101(3)(A)
• By a licensed psychiatrist when administering mechanical restraints
40 Tex. Admin. Code § 748.2501(5)
• By a licensed psychiatrist, physician, or psychologist when administering seclusion when using successive restraints
40 Tex. Admin. Code § 748.2501(2); 40 Tex. Admin. Code § 749.2102(2)(A); 40 Tex. Admin. Code § 748.2751(3); and 40 Tex. Admin. Code § 749.2231(a)
• When using restraints simultaneously
40 Tex. Admin. Code § 748.2501(2); 40 Tex. Admin. Code § 749.2101(2)(A); 40 Tex. Admin. Code § 748.2753(a)(3) and (b); 40 Tex. Admin. Code § 749.2233(a) (Emergency medications with personal restraint); and 40 Tex. Admin. Code § 748.2755(a)(3) and (b) (Mechanical restraints with emergency medications)
• When maximum length of time allowed is exceeded
40 Tex. Admin. Code § 748.2805; 40 Tex. Admin. Code § 749.2283(2)
• Also see: 40 Tex. Admin. Code § 748.2505; 40 Tex. Admin. Code § 749.2105 (content of written orders); 40 Tex. Admin. Code § 748.2507; 40 Tex. Admin. Code § 749.2107 (PRN orders); and 40 Tex. Admin. Code § 748.2807 (verbal orders to exceed maximum time allowed)
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Type of Emergency Behavior Intervention |
Are written orders required to administer the intervention for a specific child? |
Who can write orders for the use of the intervention for a specific child? |
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(1) Short personal restraint |
NO. |
Not applicable. |
|
(2) Personal restraint |
NO. However, successive restraints, a restraint simultaneous with emergency medication, and/or a restraint that exceeds the maximum time limit all require orders as specified in this subchapter. PRN orders are also permitted under §748.2507 of this title (relating to Under what conditions are PRN orders permitted for a specific child?). |
Not Applicable. |
|
(3) Emergency medication |
YES. |
A licensed physician. |
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(4) Seclusion |
YES, except written orders are not required when you provide emergency care services to the child placed in seclusion. |
A licensed psychiatrist, psychologist, or physician. |
|
(5) Mechanical restraint |
YES. |
A licensed psychiatrist. |
A review is triggered when:
• Restrained four times in a seven day period
40 Tex. Admin. Code § 748.2901(2)(A) and 40 Tex. Admin. Code § 749.2331(2)(A)
• Emergency medications used three times in a thirty day period
40 Tex. Admin. Code § 748.2901(3) and 40 Tex. Admin. Code § 749.2331(3)
• Secluded >twelve hours or three times in a seven day period
40 Tex. Admin. Code § 748.2901(4) **NOTE: Not applicable to foster care placements.
• Mechanically restrained > three hours or three times in a seven day period
40 Tex. Admin. Code § 748.2901(5) **NOTE: Not applicable to foster care placements.
Restraint/Seclusion that is NOT allowed:
*Foster care placements may never administer chemical restraints, mechanical restraints, or seclusion.
• Mechanical restraint may not be simultaneously used with seclusion or pursuant to
PRN order
40 Tex. Admin. Code § 748.2757 and 40 Tex. Admin. Code § 748.2507(5)
• No chemical restraints
40 Tex. Admin. Code § 748.1119(1); 40 Tex. Admin. Code § 749.1021(1); 40 Tex. Admin. Code § 748.2451(b); 40 Tex. Admin. Code § 749.2051(b); 40 Tex. Admin. Code § 748.2401(1); and 40 Tex. Admin. Code § 749.2001(1) (Definition)
• Prone or supine restraints except for a personal restraint for 1 minute or less
40 Tex. Admin. Code § 748.2605(b); 40 Tex. Admin. Code § 749.2205(b) & (c); 40 Tex. Admin. Code § 748.2461(b)(1); 40 Tex. Admin. Code § 749.2061(b)(1); 40 Tex. Admin. Code § 748.2553(2)(B); 40 Tex. Admin. Code § 749.2153(2)(B); 40 Tex. Admin. Code § 748.2801(2)(C); and 40 Tex. Admin. Code § 749.2281(2)(C)
Also see other relevant provisions:
• 40 Tex. Admin. Code § 748.1119 and 40 Tex. Admin. Code § 749.2021 (techniques prohibited)
• Tex. Admin. Code § 748.2303 and 40 Tex. Admin. Code § 749.1953 (may not use or threaten corporal punishment)
• 40 Tex. Admin. Code § 748.2307 and 40 Tex. Admin. Code § 749.1957 (methods of punishment prohibited)
• 40 Tex. Admin. Code § 748.2605 and 40 Tex. Admin. Code § 749.2205 (prohibited physical restraint techniques)
• 40 Tex. Admin. Code § 748.2705 (types of mechanical & other restraint devices prohibited)