Section 472-1-B-VII - FREEDOM FROM UNNECESSARY SECLUSION AND RESTRAINT IN RESIDENTIAL SETTINGSA. SECLUSION. Locked seclusion will be prohibited in residential settings.B. RESTRAINT (1) Restraint is the immobilization of a recipient's arms, legs or entire body by the use of an apparatus that is not a protective device as described in subsection VI.C. (2) Restraint may be employed only when absolutely necessary to protect the recipient from serious physical injury to self or others and shall impose the least possible restriction consistent with its purpose.(3) Restraint may be used only after less restrictive measures have proven to be inappropriate or ineffective. The extent to which less restrictive measures are attempted at the time of the incident will be governed by the degree of risk of physical harm to the recipient or others.(4) The decision to allow restraints to be employed for a particular recipient shall be made by a treatment team and shall be incorporated into the recipient's treatment or service plan.(5) The decision to place a recipient in restraints shall be made by one of the clinician with one of the following credentials: M.D., Licensed Clinical Psychologist, Licensed Clinical Social Worker, Licensed Clinical Professional Counselor or Clinical Nurse Specialist in mental health or psychiatry.(6) Within 30 minutes of being placed in restraints, the recipient shall be physically examined by a Registered Nurse.(7) Documentation of the RN's examination and assessment must be entered in the recipient's file.(8) As soon as possible, staff should make reasonable efforts to notify the recipient's legally responsible parent, guardian or custodian that the recipient has been placed in restraint and the reasons therefor.(9) Each decision for initiation or extension of restraint shall be documented, including the time the decision, the number of hours the recipient may be restrained and the conditions under which the recipient may be sooner released.(10) The need for a recipient's continuation in restraint shall be re-evaluated every two hours by a nurse. The nurse shall examine the recipient in person. This examination may be conducted with the recipient free of restraints. The nurse shall note the clinical reasons for selecting whether the recipient is examined in or free of restraints. The nurse shall assess the recipient to determine whether he or she continues to pose a danger of imminent injury to self or others. If the nurse finds such danger and that the recipient continues to require restraint, restraint use may be continued. If the number of hours contained in the original decision have elapsed, a clinician will be contacted for a decision on an extension of the use of restraint.(11) A special progress/check sheet shall be maintained for each use of restraint and shall include the following documentation:a. The indication for the use of restraint.b. A description of the behaviors that constitute the recipient's danger to self or others.c. A description of less restrictive alternatives used or considered and a description of why these alternatives proved ineffective or why they were deemed inappropriate upon consideration.(12) Every recipient placed in restraint shall be frequently monitored and released as necessary to eat, drink; bathe, toilet and to meet any special medical orders. Recipients in restraint shall have each extremity examined and the restraint loosened, sequentially, no less frequently than every 15 minutes. In instances in which blanket wraps are utilized for restraint, the recipient will be released and examined no less frequently than every hour.(13) Recipients in restraint shall be kept under constant observation.(14) A description of the recipient's behavior as observed shall be noted on the progress, record/check sheet every 1 5 minutes.(15) The total amount of time that a recipient spends in restraint may not exceed 24 hours.(16) Records required by the above provisions shall be made a part of the recipient's permanent record and copies forwarded to the clinical director or his or her designee.(17) If a recipient communicates via sign language, consideration will be given to restraining the recipient in such a manner as to permit the use of hands for communication purposes.14- 472 C.M.R. ch. 1, § B-VII