By Najera H.B. No. 3424 Line and page numbers may not match official copy. Bill not drafted by TLC or Senate E&E. A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to the regulation of the use of restraints, seclusion and 1-3 emergency medication in psychiatric hospitals and other entities 1-4 providing long term care services. 1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-6 Section 1. Subtitle C, Title 7, Health and Safety Code, is 1-7 amended by adding Chapter 579 to read as follows: 1-8 Chapter 579. USE OF RESTRAINT, SECLUSION AND EMERGENCY 1-9 MEDICATION IN PSYCHIATRIC HOSPITALS AND LONG TERM CARE FACILITIES. 1-10 Sec. 579.001. DEFINITIONS. In this chapter: 1-11 (1) "Chemical restraint" means the use of any 1-12 chemical, including pharmaceuticals, through topical application, 1-13 oral administration, injection, or other means for purposes of 1-14 restraining an individual. 1-15 (2) "Emergency" means situations in which it is 1-16 immediately necessary to restrain or seclude a person to prevent 1-17 imminent probable death or substantial bodily harm to the person 1-18 because the person overtly or continually is threatening or 1-19 attempting to commit suicide or serious bodily harm or imminent 1-20 physical harm to others because of threats, attempts or other acts 1-21 the person overtly or continually makes or commits and preventive 2-1 de-escalative, or verbal techniques have proven ineffective at 2-2 diffusing the potential for injury. 2-3 (3) "Mechanical restraint" means the use of a 2-4 mechanical device to involuntarily restrict the free movement of 2-5 the whole or a portion of an individual's body in order to control 2-6 physical activity. 2-7 (4) "Seclusion" means the placement of an individual 2-8 alone for any period of time in a hazard-free room or any other 2-9 area in which direct observation can be maintained and from which 2-10 egress is prevented. 2-11 (5) "Supportive devices" means restraints used to 2-12 postural support an individual or to assist individuals who cannot 2-13 obtain and or maintain normal bodily functioning. 2-14 (6) "Physical restraint" means the application of 2-15 physical force alone restricting the free movement of the whole or 2-16 a significant portion of an individual's body in order to control 2-17 physical activity. 2-18 (7) "PRN" means an as needed order by a physician. 2-19 (8) "Protective devices" means restraints used to 2-20 prevent involuntary self injury or to permit wounds to heal. 2-21 Sec. 579.002. IN GENERAL. (a) An entity which regulates 2-22 the care and treatment in nursing homes, hospitals (public and 2-23 private), intermediate care facilities, personal care facilities, 2-24 residential treatment centers, foster care facilities shall 2-25 promulgate rules under which physical restraint, mechanical 3-1 restraint, seclusion, emergency medication, supportive devices or 3-2 protective devices can be used, which are consistent with, but not 3-3 limited to: 3-4 (1). protecting and promoting the right of the 3-5 individual to be free from physical or mental abuse; free from 3-6 corporal punishment; free from restraints which are imposed for the 3-7 purposes of punishment, as a substitute for effective treatment or 3-8 habilitation, for the convenience of staff or due to the lack of 3-9 adequate staff; and 3-10 (2) chemical restraint is not a recognized form of 3-11 patient management in the State of Texas and is prohibited. This 3-12 includes, but is not limited to, chemical sprays that are intended 3-13 to temporal restrain an individual, including tear gas and pepper 3-14 spray; and 3-15 (3) the application of a mechanical restraint, 3-16 seclusion or administration of emergency medications is prohibited 3-17 in personal care facilities; and 3-18 (4) at least annually training shall be provided to 3-19 staff on preventive techniques and management of aggressive 3-20 behaviors. 3-21 Sec. 579.003. IMPLEMENTATION. (a) Seclusion, physical 3-22 restraint or mechanical restraints may only be used as a last 3-23 resort and only after other less restrictive alternative strategies 3-24 have failed e.g. preventive, de-escalative techniques and verbal 3-25 interventions. 4-1 (b) In making the determination that a mechanical restraint, 4-2 seclusion or emergency medication, consideration shall be 4-3 administered, consideration must be given to: 4-4 (1) medical contraindications; and 4-5 (2) psychiatric contraindications, including history 4-6 of: 4-7 (A) sexual abuse; or 4-8 (B) substance abuse. 4-9 (c) Physical restraints, mechanical restraints, seclusion or 4-10 emergency medications may only be imposed in situation which meets 4-11 the definition of emergency. 4-12 (d) Documentation must specify the specific behaviors which 4-13 constituted the emergency, the alternatives attempted, and the 4-14 individuals response to the alternative attempted. 4-15 (e) When a physical restraint, mechanical restraint or 4-16 seclusion is appropriate it must be removed or ended at the 4-17 earliest possible time. 4-18 (f) Only upon an order by a physician shall an emergency 4-19 medication, mechanical restraint, or seclusion be applied, and 4-20 only if: 4-21 (1) orders for the duration of mechanical restraints 4-22 specify: 4-23 (A) the date; and 4-24 (B) time of day; and 4-25 (C) maximum length of time. 5-1 (2) the maximum length of time for a mechanical 5-2 restraint shall not exceed four hours for adults, two hours for 5-3 adolescents and children ages 9-17, and one hour for children under 5-4 the age of 9 for which the procedure may be used unless 5-5 continuation is authorized based on a face to face evaluation by a 5-6 medical physician or registered nurse; and 5-7 (3) if the order can be continued, the maximum 5-8 duration for renewal cannot exceed 12 hours including the original 5-9 order; and 5-10 (4) PRN orders for mechanical restraints or seclusion 5-11 shall be prohibited; and 5-12 (5) PRN orders for emergency medications are 5-13 prohibited with the exception of foster care facilities. 5-14 (g) Water and bathroom privileges must be offered at least 5-15 every two hours during seclusion or during the application of a 5-16 mechanical restraint. 5-17 (h) Vital signs must be taken every fifteen minutes through 5-18 the duration of a mechanical restraint. 5-19 (i) Continuous observation must occur of individuals placed 5-20 in a physical or mechanical restraint, including monitoring of 5-21 breathing. 5-22 (j) Continuous observation must occur of individuals placed 5-23 in seclusion who have also been administered emergency medication. 5-24 (k) A consultation with a clinician not part of the 5-25 treatment team must occur when a mechanical restraint, seclusion or 6-1 emergency medication is administered more than twice within a 6-2 thirty day period, to explore alternative treatment strategies. 6-3 (l) The concurrent use of emergency medication with 6-4 seclusion or mechanical restraint must be clinically justified and 6-5 documented. 6-6 (m) Mechanical restraint or seclusion may be used during 6-7 medical or dental care or rehabilitation if necessary and a regular 6-8 and customary part of care or rehabilitation treatment. 6-9 (n) Every death or serious physical injury, as defined in 6-10 the state penal code, which happens during or within 48 hours 6-11 subsequent to a physical restraint, mechanical restraint or 6-12 seclusion must be reported to law enforcement and to the 6-13 appropriate regulatory agency for investigation. 6-14 (o) The entity shall file incident reports as required under 6-15 section (579.006). 6-16 Sec. 579.004. USE OF SUPPORTIVE DEVICES. (a) The use of 6-17 supportive devices are considered an adjunct to proper care of an 6-18 individual but must be reviewed by the treatment team and a plan 6-19 developed to identify and overcome the need for the protective 6-20 device. 6-21 (b) Supportive devices may not be used as a substitute for 6-22 appropriate nursing rehabilitative or habilitative care. 6-23 Sec. 579.005. USE OF PROTECTIVE DEVICES. (a) The use of 6-24 protective devices may be used to prevent self injury but must be 6-25 reviewed by the treatment team and a plan developed to identify and 7-1 overcome the need for the protective device. 7-2 (b) Protective devices may not be used as a substitute for 7-3 appropriate nursing rehabilitative or habilitative care. 7-4 Sec. 579.006. REPORTS. (a) Data relating to the 7-5 administration of mechanical restraints, seclusion and emergency 7-6 medication shall be collected by each regulating agency on a 7-7 quarterly and annual basis to be analyzed, with summary reports 7-8 submitted to the governor and the presiding officer of each house 7-9 of the legislature. The data shall include: 7-10 (1) the number of patients who received mechanical 7-11 restraints, seclusion or emergency medication; and 7-12 (2) the age, sex and race of the persons receiving the 7-13 mechanical restraint, seclusion or emergency medication; and 7-14 (3) any serious physical injuries or deaths which 7-15 occurred during or within 48 hours of the physical restraint, 7-16 mechanical restraint, seclusion or emergency medication; and 7-17 (4) autopsy findings if death followed within 14 days 7-18 after the date of the administration of the physical restraint, 7-19 mechanical restraint, seclusion or emergency medication; and 7-20 (5) the funding source for the individual. 7-21 SECTION 2. This Act takes effect September 1, 1999. 7-22 SECTION 3. The importance of this legislation and the 7-23 crowded condition of the calendars in both houses create an 7-24 emergency and an imperative public necessity that the 7-25 constitutional rule requiring bills to be read on three several 8-1 days in each house by suspended, and this rule is hereby suspended.