65E-9.013. Restraint, Seclusion, and Time Out

(1) General requirements.

(a) Providers shall comply with guidelines for the use of restraint, seclusion and time-out as specified in Chapter 394, F.S., in addition to the guidelines specified in this rule.

(b) Restraint or seclusion shall not result in harm or injury to the child and shall be used only:

1. To ensure the safety of the child or others during an emergency safety situation; and

2. Until the emergency safety situation has ceased and the child’s safety and the safety of others can be ensured, even if the restraint or seclusion order has not expired.

(c) Restraint or seclusion shall not be used for purposes of punishment, coercion, discipline, convenience, or retaliation by staff or to compensate for inadequate staffing.

(d) An order for restraint or seclusion shall not be issued as a standing order or on an as-needed basis.

(e) Restraint or seclusion shall be used in a manner that is safe and proportionate to the severity of the behavior and the child’s chronological and developmental age; size; gender; physical, medical and psychiatric condition, including current medications; and personal history, including history of physical or sexual abuse.

(f) Only staff who have completed a competency-based training program that prepares them to properly use restraint or seclusion shall apply these procedures to children.

(g) Restraint that impedes respiration (e.g., choke hold or basket hold), places weight on the child’s upper torso, neck, chest or back, or restricts blood flow to the head is prohibited.

(h) Ambulatory or walking restraints (e.g., shackles that bind the ankles and waist-wrist shackles) may only be used during transportation under the supervision of trained staff. The use of ambulatory or walking restraints is prohibited except for purposes of off-premise transportation.

(i) The provider’s medical or clinical director shall be responsible for providing oversight of ongoing monitoring, quality improvement and staff training in the use of restraint and seclusion and in the use of less intrusive, alternative interventions.

(2) Provider procedures. The provider’s procedures shall address the use of restraint, seclusion and time-out. A copy of the procedures shall be provided to children and their parents or guardians, foster parents and guardian ad litem, if applicable, upon admission, to all staff, and to the department. The procedures shall include provisions for implementing the requirements of this section and the provider’s strategies to:

(a) Reduce and strive to eliminate the need for and use of restraint and seclusion;

(b) Prevent situations that might lead to the use of restraint or seclusion;

(c) Use alternative, non-intrusive techniques in the prevention and management of challenging behavior;

(d) Train staff on how restraint and seclusion are experienced by children and the effect they have on children with a history of trauma; and

(e) Preserve the child’s safety and dignity when restraint or seclusion is used.

(3) Authorization of restraint or seclusion.

(a) Restraint or seclusion shall be used and continued only pursuant to an order by a board certified or board eligible psychiatrist licensed under Chapter 458, F.S., or licensed physician with specialized training and experience in diagnosing and treating mental disorders and who is the child’s treatment team physician. If the child’s treatment team physician is unavailable, the physician covering for the treatment team physician may meet these qualifications. Physicians allowed to order seclusion and restraint, pursuant to this rule, must be trained in the use of emergency safety interventions prior to ordering them.

(b) The ordering physician shall order the least restrictive intervention that is most likely to be effective in resolving the emergency safety situation.

(c) If the ordering physician is not available on-site to order the use of restraint or seclusion, a verbal telephone order shall be obtained by, at a minimum, a registered nurse or other licensed staff, such as a licensed practical nurse (LPN), at the time the restraint or seclusion is initiated or immediately after it ends. At the time the order is received, the registered nurse or other licensed staff, such as an LPN, shall consult with the ordering physician about the child’s physical and psychological condition. The order and consultation shall be documented in the child’s case file. If an emergency exists where restraint or seclusion is needed but the physician is not present or available by telephone, a psychiatric nurse, advanced nurse practitioner, physician assistant, or registered nurse may apply the restraint or place the child in seclusion, with follow up information provided to the physician as soon as is reasonably possible.

(d) The verbal order given by the physician shall be followed with their signature verifying the verbal order within seven calendar days and the signed verification shall be maintained in the child’s case file.

(e) The ordering physician shall be available to staff for consultation, at least by telephone, throughout the period of the intervention.

(f) Each order for restraint or seclusion shall:

1. Be limited to no longer than the duration of the emergency safety situation;

2. Not exceed two hours for children or adolescents ages nine through seventeen or one hour for children under age nine; and

3. Be documented, whether verbal or written, and maintained in the child’s case file.

(g) If restraint or seclusion exceeds a total of six hours within a 24-hour period for a child age nine through seventeen or a total of three hours for a child under age nine, there must be a written explanation as to why the child was not transferred to a more acute program.

(h) If a child requires the use of seclusion or restraint at any time during their stay, the treatment team shall formally review and actively address their use during the child's regularly scheduled treatment team review meetings, no less frequently than two times per month, until deemed no longer necessary. The reviews shall assess the frequency, patterns and trends, and identify ways to prevent the need for seclusion and restraint use. The treatment team's review of and efforts to eliminate seclusion and restraint use with a specific child shall be documented as part of the child's treatment team review. In addition, if a child is restrained a total of two times within a thirty day period, or is in seclusion a total of three times within a thirty day period, the treatment team will oversee the development and monitor the implementation of a formal child-specific plan to aggressively address the need for seclusion and restraint use with that child.

(i) Within one hour of the initiation of restraint or seclusion, the ordering physician or other licensed practitioner, as permitted by the state and facility, (including a psychiatric nurse, advanced nurse practitioner, physician assistant, or registered nurse) trained in the use of emergency safety interventions, shall conduct a face-to-face assessment of the physical and psychological well being of the child, including:

1. The child’s physical and psychological status;

2. The child’s current behavior;

3. The appropriateness of the intervention measures; and

4. Any physical or psychological complications resulting from the intervention.

(j) Each order for restraint or seclusion shall include:

1. The ordering physician’s name;

2. The date and time the order was obtained; and

3. The emergency safety intervention ordered, including the length of time for which the physician authorized its use, which length of time shall not exceed the time limits set forth in subsection 65E-9.013(3)(f)1.-.3, F.A.C.

(4) Documentation. Staff shall document the intervention in the child’s record, with documentation completed by the end of each shift during which the intervention begins and continues. Documentation shall include:

(a) Each order for restraint or seclusion;

(b) The time the emergency safety intervention began and ended;

(c) The specific circumstances of the emergency safety situation, the rationale for the type of intervention selected, the less intrusive interventions that were considered or tried and the results of those interventions;

(d) Time-specific assessments of the child’s physical and psychological condition;

(e) The name, position, and credentials of all staff involved in or witnessing the emergency safety intervention;

(f) Time and date of notification of the child’s parent or guardian and guardian ad litem;

(g) The behavioral criteria and assistance provided by staff to help the child meet the criteria for discontinuation of restraint or seclusion;

(h) Summary of debriefing of the child with staff;

(i) Description of any injuries sustained by the child during or as a result of the restraint or emergency safety intervention and treatment received for those injuries;

(j) Review and revise, if necessary, the child’s treatment plan, including a description of procedures designed to prevent the future need for and use of restraint or seclusion; and

(k) Before restraint or seclusion were ordered for the child, the ordering physician assessed whether there were pre-existing medical conditions or physical disabilities, history of sexual or physical abuse, or current use of psychotropic medication that could present a risk to the child and results of such review are documented in the order for restraint or seclusion and the child’s record.

(5) Consultation with treatment team physician. If the physician ordering the use of restraint or seclusion is not the child’s treatment team physician, the ordering authorized to receive the verbal order shall:

(a) Consult with the child’s treatment team physician as soon as possible and inform the team physician of the emergency safety situation that required the child to be restrained or placed in seclusion; and

(b) Document in the child’s record the date and time the team physician was consulted.

(6) Notification.

(a) Notification upon admission. At admission, the provider shall:

1. Explain and provide a written copy of the provider’s procedures regarding the use of restraint and seclusion to the child, the child’s parent or guardian, and guardian ad litem, if applicable. The provider shall document that the child and the parent or guardian, and guardian ad litem were informed of the provider’s policies on the use of restraint and seclusion. This documentation shall be filed in the child’s record.

2. Communicate the procedures in a language the child and the parent or guardian understand, including American Sign Language or through an interpreter or translator if needed.

3. Include in the procedures contact information, including phone number and mailing address, of the Advocacy Center for Persons with Disabilities, Inc.

4. Consult with the child’s parent or guardian and foster parent and guardian ad litem, if applicable to determine if there are any known physical or psychological risks that would rule out the use of such interventions for the child. The results of such interview shall be documented in the child’s record.

(b) Notification of use of restraint or seclusion.

1. As soon as possible, but no later than 24 hours after the initiation of each emergency safety intervention, the provider shall notify the parent or guardian that the child has been restrained or placed in seclusion.

2. The provider shall document in the child’s record that the parent or guardian was notified, including the date and time of notification and the name of the staff person providing the notification.

(7) Monitoring of the child during and immediately after restraint.

(a) Staff trained in the use of emergency safety interventions shall be physically present and continually visually assessing and monitoring the physical and psychological well-being of the child and the safe use of restraint throughout the duration of the emergency safety intervention.

(b) If the emergency safety situation continues beyond the time limit of the physician’s order for the use of restraint, the staff person authorized to receive the verbal order, as identified in paragraph 65E-9.013(4)(c), F.A.C., shall immediately contact the ordering physician to receive further instructions or new orders for the use of restraint and shall document such notification in the child’s case file.

(c) A physician, or other licensed staff member as identified in paragraph 65E-9.013(4)(i), F.A.C., trained in the use of emergency safety interventions, shall evaluate and record the child’s physical condition and psychological well-being immediately after the restraint is removed.

(8) Monitoring of the child during and immediately after seclusion.

(a) Staff trained in the use of emergency safety interventions and in assessment of suicide risk shall be physically present in or immediately outside the seclusion room, continually visually assessing, monitoring, and evaluating the physical and psychological well-being of the child in seclusion. Video or auditory monitoring shall not be used as substitutes for this requirement.

(b) If the emergency safety situation continues beyond the time limit of the physician’s order for the use of seclusion, the staff person authorized to receive the verbal order, as identified in paragraph 65E-9.013(3)(c), F.A.C., shall immediately contact the ordering physician to receive further instructions or new orders for the use of seclusion and such notification shall be documented and maintained in the child’s case file.

(c) A physician or other licensed staff member, as identified in paragraph 65E-9.013(3)(i), F.A.C., trained in the use of emergency safety interventions, shall evaluate the child’s physical condition and psychological well-being immediately after the child is removed from seclusion and documentation of such evaluation shall be maintained in the child’s case file.

(d) Staff shall immediately obtain medical treatment from qualified medical personnel for a child injured during or as a result of an emergency safety intervention.

(9) Discontinuation of restraint or seclusion. As early as feasible in the restraint or seclusion process, the child shall be told the rationale for restraint or seclusion and the behavior criteria necessary for its discontinuation that ensures the safety of the child and others. Restraint or seclusion shall be discontinued as soon as the child meets the behavioral criteria.

(10) Post-restraint or seclusion practices.

(a) After the use of restraint or seclusion, staff involved in an emergency safety intervention and the child shall have a face-to-face discussion, which is also known as a debriefing. Whenever possible, subject to staff scheduling, this discussion shall include all staff involved in the intervention. The child’s parent or guardian shall be invited to participate in the discussion. The provider shall conduct the discussion in a language that is understood by the child and the child’s parent or guardian. The discussion shall provide both the child and staff the opportunity to discuss the circumstances resulting in the use of restraint or seclusion and strategies to be used by the staff, the child, or others to prevent the need for the future use of restraint or seclusion. The discussion must occur within 24 hours of the emergency intervention, subject to the following exceptions:

1. Allowances may be made to accommodate the schedules of the parent(s) or legal guardian(s) of the child when they request an opportunity to participate in the debriefing and when staff deem their participation appropriate.

2. Allowances may be made to accommodate shift changes, vacation schedules, illnesses, and all applicable federal, state, and local labor laws and regulations.

(b) After the use of restraint or seclusion, the staff involved in the emergency safety intervention, and appropriate supervisory and administrative staff, shall conduct a debriefing session that includes a review and discussion of:

1. The emergency safety situation that required the intervention, including a discussion of the factors that caused or preceded the intervention;

2. Alternative, less intrusive techniques that might have prevented the need for the restraint or seclusion;

3. The procedures, if any, that staff are to implement in the future to prevent any recurrence of the use of restraint or seclusion; and

4. The outcome of the intervention, including any injuries that resulted from the use of restraint or seclusion and the treatment provided for those injuries.

(c) Staff shall document in the child’s record that both debriefing sessions took place and shall include in that documentation the names of staff present for the debriefing, names of staff excused from the debriefing, and any changes to the child’s treatment plan or facility procedures that resulted from the debriefings.

(d) The provider shall maintain a record of each emergency safety situation, the interventions used, and their outcomes. These records shall be maintained in a manner that allows for the collection and analysis of data for agency monitoring and provider performance improvement and shall be available for such purposes upon request.

(e) Staff shall document in the child’s record all injuries that occur during or as a result of an emergency safety intervention, including injuries to staff resulting from that intervention.

(f) Staff involved in an emergency safety intervention that results in an injury to a child or staff shall meet with supervisory staff and evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.

(g) The provider shall immediately notify the child’s parent or guardian of any serious occurrence, including a child’s death, a serious injury to a child, or a suicide attempt. The provider shall also report the serious occurrence to the Department, the agency, and the state advocacy council the same day or no later than close of business the next business day for a serious occurrence that occurs after 5:00 p.m. or over a weekend. The report shall include the name of the child involved in the serious occurrence, a description of the occurrence, and the name, street address, and telephone number of the facility.

(11) Time-out.

(a) Time-out shall be used only for the purpose of providing a child with the opportunity to regain self-control and not as a consequence or punishment.

(b) If time-out is used with a child, child-specific guidelines for the use and duration of time-out, based on the professional judgment of the child’s treatment team, shall be specified in the child’s treatment plan, upon consideration of the child’s age, maturity, health, and other factors. In addition, the child’s parent or guardian shall sign an informed consent form detailing the circumstances under which time-out will be used and how the procedure is to be implemented.

(c) Time-out shall be initiated only by staff who have completed competency-based training in the use of time-out and such training shall be documented in their personnel record.

(d) Time-out may take place either in or away from the area of activity or other children, such as in the child’s room.

(e) The designated area shall be a room or area that is part of the living environment the child normally inhabits or has access to during routinely scheduled activities and from which the child is not physically prevented from leaving.

(f) If the child requires physical contact in order to move to the area or room, staff shall end the contact immediately once the child is in the designated area.

(g) The child shall not be physically prevented from leaving the time-out area.

(h) The criterion for being able to end time-out without further intervention shall be specified to the child at this time in a neutral manner.

(i) Time-out shall be terminated after the child meets the behavioral criterion for the specified time period, which shall not exceed 5 minutes at a time. If the child meets the criterion earlier, staff shall end the procedure immediately.

(j) If the child has not been able to meet the criterion for exiting time-out within 30 minutes, staff shall notify the ranking clinician on duty or on-call, who shall assess how the procedure was implemented, assess the child’s condition, and determine whether to end the procedure, reduce the exit criterion, or continue the procedure.

(k) When time-out is imposed, staff shall directly and continuously observe the child.

(l) The child’s treatment team shall review the use of time-out during that child’s treatment team meetings, but no less frequently than two times per month. This review shall consist of assessing the frequency, patterns and trends, questioning the function(s) of the behavior(s) that resulted in the use of time-out, possible ways to prevent the behavior(s) and the appropriateness of the exit criteria used.

(m) For each instance that time-out is used, staff who initiate the procedure shall document in the child’s record:

1. The circumstances leading to the use of time-out;

2. The specific behavior criteria explained to the child that would allow for discontinuation of time-out;

3. When and how the child was informed of the behavior criteria;

4. The time the procedure started and ended; and

5. Any injuries sustained and treatment provided for those injuries.

(n) A separate time-out log shall be maintained that records:

1. The shift;

2. The staff who initiated the process;

3. The time the procedure started and ended;

4. The date and day of the week of each episode;

5. The age and gender of the child; and

6. Client ID.

Specific Authority 394.875(8) FS. Law Implemented 394.875 FS. History–New 7-25-06, Amended 9-24-08.