(a) Purpose. This rule establishes the criteria, procedures, and limitations for use of four-point restraints when used for medical or mental health purposes.
(b) Applicability.
  (1) This rule applies to all residential facilities operated by the Texas Juvenile Justice Department (TJJD) that are authorized to administer four-point restraints.
  (2) This rule applies only to four-point mechanical restraints. For all other types of restraint used for medical or mental health purposes, provisions of §380.9723 of this title apply.
(c) Additional References. For criteria on administering a psychotropic drug in a psychiatric emergency when a youth will not give consent for the administration, see §380.9192 of this title.
(d) Definitions. For definitions of terms used in this section, see §380.9175 of this title.
(e) General Provisions.
  (1) Four-point restraints may only be used for medical or mental health purposes as described by this rule. Four-point restraints may not be used for any other purpose.
  (2) Restraint equipment used for medical or mental health purposes must be used only in a manner consistent with its intended design and purpose.
  (3) Only restraint equipment approved by the executive director or designee may be used in TJJD facilities.
  (4) TJJD staff who will participate in the application of four-point restraints or monitoring, managing, or approving the restraint must receive special training and may not participate in its implementation until the training has been received. The training will include proper use and application of restraint devices and applicable TJJD policies and guidelines regarding the implementation, documentation, and possible continuation of the restraint.
  (5) If facility resources are not sufficient to support the procedural requirements specified in this rule, four-point restraints must not be used.
  (6) A medical provider must be consulted prior to placing a youth in a four-point restraint device if the youth is pregnant or has a seizure disorder or any other medical condition that contraindicates such restraint.
  (7) The facility administrator or designee must ensure that the parent/guardian of a youth placed in a four-point restraint is notified within 24 hours after the restraint is initiated.
(f) Four-Point Restraints for Medical Purposes.
  (1) Authorized Facilities.
Four-point medical restraints are authorized only at high restriction facilities that:
    (A) operate an on-site infirmary; and
    (B) have been authorized by the executive director or designee to administer four-point restraints.
  (2) Criteria for Use. Medical restraints may be used only to administer medical treatment to a resistant youth when failure to administer the treatment could have serious health implications as determined by a physician or mid-level practitioner (such as a nurse practitioner or physician assistant).
  (3) Authorization for Use.
    (A) Only a medical provider may order a medical restraint. The order must be based upon a determination that:
      (i) all appropriate, less restrictive interventions have proved unsuccessful in controlling the youth's behavior to a degree that would allow the medical treatment to be administered; and
      (ii) transfer to a local emergency room or other appropriate facility is not immediately feasible.
    (B) An order for medical restraint must specify the type of restraint to be used, duration of the restraint, any special instructions, and justification for the restraint.
    (C) Prior to the expiration of the first hour, a registered nurse must contact the medical provider to develop a treatment plan, if the restraint is still needed. The treatment plan must include transfer to a local emergency room or other appropriate facility if the need for restraint exceeds one hour.
  (4) Procedural Requirements.
    (A) A medical provider or nurse must be present during the application of restraints.
    (B) Youth are provided:
      (i) 15-minute checks by healthcare staff to assess the youth's condition, including circulation, position, and open airway. Such checks must be documented in the youth's medical record;
      (ii) range-of-motion exercises performed by a nurse at least every 30 minutes for a period of at least five minutes;
      (iii) regularly scheduled meals and drinks;
      (iv) continuous visual supervision by staff; and
      (v) opportunities for elimination of bodily waste as needed.
    (C) A medical restraint must be terminated upon a determination by the medical provider that the youth's behavior no longer justifies application of medical restraints or expiration of the provider's order, whichever occurs first.
(g) Four-Point Restraints for Mental Health Purposes.
  (1) Authorized Facilities. Four-point mental health restraints are authorized only at facilities designated by the executive director or designee.
  (2) Criteria for Use.
    (A) Four-point restraints for mental health purposes are authorized for use only when the restraint is necessary to prevent serious self-injury and all appropriate, less restrictive interventions have proven unsuccessful in controlling the youth's self-injurious behavior, as determined by a designated mental health professional or a psychiatric provider.
    (B) The restraint must be terminated as soon as the youth's behavior indicates the threat of imminent self-injury is absent, as determined by a designated mental health professional or psychiatric provider.
  (3) Authorization to Initiate and Continue Restraint.
    (A) Only a designated mental health professional or a psychiatric provider may authorize the initiation of a mental health restraint.
    (B) At least one staff member trained specifically in mental health restraint techniques must be involved in the application of the restraint. If at least one trained staff member is not available, the restraint may not be used.
    (C) Before the end of the first hour of restraint, the designated mental health professional or psychiatric provider must determine whether to continue the restraint.
    (D) Before the end of the second hour of restraint:
      (i) a mental health professional must conduct a face-to-face assessment of the youth; and
      (ii) the designated mental health professional or psychiatric provider must determine whether to continue the restraint.
    (E) Before the end of the fourth hour of restraint and at least once every four hours thereafter:
      (i) a mental health professional must conduct a face-to-face assessment of the youth;
      (ii) the designated mental health professional and psychiatric provider must be notified of the youth's status; and
      (iii) the designated mental health professional or psychiatric provider must determine whether to continue the restraint.
    (F) No order or approval for mental health restraint may be in force for longer than eight hours without consultation with a psychiatric provider.
    (G) No order or approval for mental health restraint may be in force for longer than 12 hours without:
      (i) direct observation of the youth by the designated mental health professional;
      (ii) a written order to extend the restraint from the psychiatric provider; and
      (iii) written instructions from the designated mental health professional regarding continued assessments and monitoring.
  (4) Procedural Requirements.
    (A) A specially trained, on-site staff member must manage the entire restraint incident. Duties of this staff member include:
      (i) ensuring policy and procedure are followed;
      (ii) notifying the designated mental health professional or psychiatric provider of any significant changes in the youth's behavior;
      (iii) ensuring required documentation and notifications are completed; and
      (iv) assigning one or more staff members to:
        (I) provide continuous supervision of the youth for the duration of the incident;
        (II) document the youth's behavior and emotional state; and
        (III) facilitate communication between all staff members involved in the restraint.
    (B) Staff must ensure the youth's personal dignity by providing a protected environment and as much privacy as possible.
    (C) Youth must be provided:
Cont'd...