1. (a) At the time that any emergency treatment, seclusion, or restraint is administered in a facility pursuant to Cor 502.03, the physician or APRN administering or directing such treatment, or a person acting under his or her direction, shall promptly record the circumstances pertaining to the personal safety emergency.

2. (b) The person completing a record pursuant to (a) above shall include the following:

   1. (1) The resident’s name;
   2. (2) The date and time when the report is completed;
   3. (3) The physician or APRN’s name;
   4. (4) A description of the resident’s physical or behavioral status and the act or pattern of behavior which constitutes the emergency;
   5. (5) The names of any witnesses other than the resident;
   6. (6) A description of any alternatives attempted or considered prior to declaring a personal safety emergency;
   7. (7) Any treatment limitations;
   8. (8) A description of the specific emergency treatment, seclusion, or restraint ordered; and
   9. (9) The physician’s or APRN’s signature.
3. (c) As soon as possible following an involuntary emergency treatment, seclusion, or restraint, facility medical or nursing staff, or both, shall document the incident in the resident’s medical record.

4. (d) As soon as possible following the resolution of the emergency situation, medical staff shall:

   1. (1) Address any physical injuries or trauma that might have occurred as a result of the episode;

   2. (2) Hold and document a discussion with the resident to:

      1. a. Review the circumstances that led up to the emergency with the resident involved;
      2. b. Ascertain the resident’s willingness or desire to involve his or her clinician in a debriefing to discuss and clarify their perceptions about the episode and to identify additional alternatives or treatment plan modifications;
      3. c. Hear and document the resident’s perspective of the episode;
      4. d. Discuss and clarify any possible misperceptions the resident or staff might have concerning the incident;
      5. e. Identify with the resident any environmental changes or alternative interventions to reduce the potential for additional episodes; and
      6. f. Ascertain whether the resident’s rights and physical well-being were addressed during the episode and advise the resident of the process to address perceived rights grievances; and
   3. (3) Support the individual’s re-entry into his or her assigned housing.
5. (e) Within one business day, the individual’s clinician shall, after discussion with the resident, modify the treatment plan as needed through a treatment team review including areas noted in (d)(1)-(3) above and seek an informed decision on that plan by the resident.

6. (f) A review of the clinical appropriateness of the use of seclusion or restraint shall be conducted:

   1. (1) As authorized by the facility’s psychiatric medical director;
   2. (2) On the next business day following a personal safety emergency;
   3. (3) To assess compliance with the requirements of Cor 503.02;
   4. (4) To consider and take any action needed to prevent the recurrence of the same or similar personal safety emergencies; and
   5. (5) By the facility’s chief of security.

Source. (See Revision Note at chapter heading for Cor 500) #12793, eff 5-25-19