Critical Incidents and Restraints Comments

Comments by Texas Council for Developmental Disabilities and Disability Rights Texas

May 30, 2013

Restraint Data Collection

We’re delighted that DADS is proposing to collect information in addition to what is required by SB 325. The committee that worked on the data collection piece were suppose to have developed a method to be able to compare across systems/agencies. That would necessitate that the data collection piece addressed in the concerns mentioned about size and numbers of individuals. The state hospitals across the country grappled and achieved that through NASMHPD. Again this should have already been addressed in the methodology that was agreed upon with the SB 325 workgroup. Bill Manlove at DSHS would be a good person to talk with about this, as would Peggy Perry the Director of MH facilities at DSHS. 

In addition and recognizing that institutions and community have substantial differences, we also suggest reviewing, comparing, and when appropriate duplicating some of the appropriate definitions,  protections and reporting as has been agreed to in SSLC policies that have been updated in the last 12 to 24 months. Disability Rights Texas has provided significant input on those policies and they should, at a minimum, be a resource to policy development and implementation so that program participants are safe and can be assured the same protections regardless of where they live. Standardized definitions across systems are critical and should be the same as much as possible, rather than reinventing the wheel; for example, definitions of various forms of restraints such as chemical or mechanical. We should take advantage of experiences and best practices from the mental health system and what has been revised within the SSLC system.

The HCS rule currently allows restraint as part of a behavior support plan. This is no longer allowed in SSLCs. SSLCs more recently developed crisis intervention plans to be used in limited circumstances and that may include restraint or restraint can be used in an emergency situation when a person is at imminent danger to oneself or others. We should be capturing emergency restraints being used and restraints used as part of the individual’s behavior support plan (programmatic) and start the process to review the rule prohibiting the BMP restraint option in HCS. We can count them separately but need to report both. We recommend that you differentiate data from restraints used for medical, postural, or supports (although we know that is sometimes manipulated). Regarding any restraint, you would want to know what behavior precipitated and was used to justify any and all restraints, including how long the plan has been in place and the outcome. If any plan is used to include restraint, data should also include how long the plan has been in place and without a positive change, and recognize that the person is not making the connection between the behavior and the restraint and may see the hold simply as a punishment or other factors beyond the person’s control are at play. See SSLC policies regarding requirements to fade and eliminate restraints.

We anticipate a resistance to collect the following data, however, we strongly recommend that WS&C should be looking for this data during survey for providers with restraint rates above the aggregate average.

In addition to the use of restraints, additional data must include info about the precipitating event. Frequently, staff or other environmental triggers or persons cause the person to lose control by their interactions with them. Staff will sometimes try to force a person to do something and if the person resists the staff invade the person’s space which will elicit the response of the person striking out (most of us would). When the person strikes out it then supposedly “justifies” the restraint. DADS should be collecting and analyzing the precipitating event, not just starting when the emergency behavior occurred, i.e. person tried to hit staff…well why? What happened before the event? What was the antecedent? DADS should also collect data on what attempts were made to de-escalate the situation and what was the result. We need to learn what works for folks and what did not so they know what to use. We need to know not only what did the staff say but more importantly how did they say it. Yelling “calm down” probably is not going to result in the person de-escalating. Was it possible for the staff to simply take a step away from the person and give them space and time to de-escalate? Typically staff move closer, not further away.

Equally important is knowing whether the trigger for the behavior leading to a restraint was related to a rights restriction so that the rights information that is located in a different system can be reviewed, the consequences understood and alternatives pursued.

If the restraints are used due to self injurious behavior, what clinical plan is in place to decrease the self injurious behavior from reoccurring, rather than just intervening at that moment. If the plan is not working do they use consultants to try to come up with more creative plans?  

It is also helpful to capture data on incidents that could have resulted in a restraint but staff were successful in intervening without a restraint. Doesn’t DADS want to know how that occurred and replicate it? SB 325 speaks to that as well (preventative actions or techniques). Also in debriefing about those things it makes it easier for staff to participate and speak freely because it does not seem as punitive only looking at what was done wrong…maybe we should also look at what was done correctly which resulted in avoiding the use of a restraint.

Part of the treatment plan should be helping individuals improve self control. That involves identifying what causes the person to get upset and what types of things engage them sufficient to help them de-escalate. We have to invite people to de-escalate, it doesn’t just happen. It sure doesn’t happen when you just tell the person to “calm down, stop, no or don’t”. Those words tend to have the opposite effect.  If we simply use external control without teaching the person how to increase self control they will always be dependent and less successful in living in the community.

It is critical to engage the individual in determining and understanding the restraints policy and as related to that individual and developing meaningful alternative communication and other strategies. 

It is important to identify and collect information focusing on trauma and whether or not the person is hypervigilent because of traumatic experiences that cause the person to be hypervigilent and over react. That would actually be “treatment” getting to the underlying cause of the behavior. For example if the person was sexually or physically abused at bedtime, the person may exhibit more behaviors at bedtime as a result of the trauma. 

The categories for where the restraint occurred should include day program, employment, community class, community event/activity, during transportation (van, car, public transportation).

These comments are provided by:

Jessica Ramos, MSW
Public Policy Director
Texas Council for Developmental Disabilities
Office 512.437.5417
Cell 512.423.7050
Susan Murphree
Sr. Policy Specialist
Disability Rights Texas
Office 512.407.2754
Cell 512.913.4501