(a) Expectations.
  (1) A facility must implement and operationalize statewide policy addressing the use of restraint.
  (2) At least one person trained as a restraint monitor must be on duty at all times to respond to the initiation of restraint procedures in a behavioral crisis, immediately if possible but in no case in more than 15 minutes. If data suggests a high number of incidents of restraint, additional restraint monitors may be required.
  (3) If an individual is in restraint at the time of shift change, staff must communicate and coordinate between shifts to provide continuity of care.
  (4) A licensed nurse must assess, for injuries and other negative health effects, an individual who has been restrained; determine if the individual's vital signs are stable; and document the individual's mental status as soon as possible but within 30 minutes after the initiation of restraint. Staff must continuously monitor the individual until the licensed nurse arrives.
  (5) A mechanical or physical restraint administered to an individual must:
    (A) be the least restrictive restraint effective to prevent imminent physical harm in a behavioral crisis, or to safely and effectively implement a medical or dental procedure, or to prevent or mitigate the documented danger of self-injurious behavior;
    (B) be used for the shortest period of time necessary to prevent imminent physical injury, to safely and effectively implement a medical or dental procedure, or to prevent or mitigate the documented danger of self-injurious behavior;
    (C) end immediately once the imminent risk of physical injury abates;
    (D) be applied with the minimum amount of force or pressure necessary to prevent harm to the individual and others; and
    (E) be used in the safest, least restrictive, most humane, and most respectful manner possible.
  (6) Staff must attempt to provide an environment that safeguards the individual's personal dignity, privacy, and well-being while ensuring safety.
  (7) Staff must provide continuous one-to-one supervision to individuals while in restraint. Individuals receiving medical restraints must receive supervision as ordered by the PCP or dentist in accordance with facility procedures. The director may approve an alternate level of supervision based on the IDT's clinical justification and recommendation.
  (8) Staff must respond appropriately to signs or symptoms of restraint-related injuries or distress, including an immediate release from restraint and checks by medical staff.
  (9) If an emergency evacuation or an evacuation drill occurs while an individual is in restraint, staff must respond as described in the facility's policies and procedures to ensure the individual's safety.
  (10) Staff must allow an individual who has been released from restraint time to recover and return to regular activities, including the opportunity to relax and exercise restrained limbs, to drink fluids, to toilet, to complete a snack or meal, and to receive prescribed medications.
  (11) Staff must take all necessary steps to avoid causing undue physical discomfort, harm, or pain to the individual while initiating and implementing restraint.
  (12) A facility must obtain legally adequate consent for a crisis intervention plan, medical restraint plan, or protective mechanical restraint plan for self-injurious behavior. A plan must be reviewed by the Behavior Support Committee and the facility director and approved by the Human Rights Committee before implementation.
  (13) An authorization to use or extend physical restraints in response to a behavioral crisis may be in effect no longer than 12 consecutive hours.
(b) Allowed uses. Restraints may only be used to protect an individual or others from imminent physical injury resulting from:
  (1) a behavioral crisis;
  (2) a medical or dental procedure; or
  (3) documented self-injurious behavior for which intensive, one-to-one supervision and treatment have not sufficiently reduced the risk of self-injury.
(c) Prohibitions.
  (1) A restraint may not be used on an individual unless the restraint is necessary to prevent imminent physical injury to the individual or another person.
  (2) A restraint may not be used for punishment, disciplinary purposes, retaliation, retribution, or convenience or as a substitute for treatment or habilitation.
  (3) A restraint may not be used on an individual as part of a positive behavior support plan.
  (4) Prone or supine restraint may not be used.
  (5) A restraint may not be used if it:
    (A) secures the individual to a stationary object while he or she is in a standing position;
    (B) obstructs the individual's airway, including the placement of anything in, on, or over his or her mouth or nose;
    (C) impairs the individual's breathing by putting pressure on his or her torso;
    (D) interferes with the individual's ability to communicate;
    (E) extends muscle groups away from each other;
    (F) uses hyperextension of joints;
    (G) uses pressure points or pain; or
    (H) is prohibited by the individual's medical orders or ISP or is medically contraindicated.
  (6) A standing order for restraint may not be used.

Source Note: The provisions of this §967.27 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927