Section 52.42. Behavior management and control.

 

(1)   Definitions. In this section:

(a) "Behavior management and control" means techniques, measures, interventions and procedures applied in a systematic fashion to prevent or interrupt a resident's behavior which threatens harm to the resident or others or to property and which promote positive behavioral or functional change fostering resident self-control.

(b) "Informed consent document" means a document signed by a resident's parent or guardian and legal custodian or under a court order or under another lawful authority which gives written informed consent for use of a locked unit for a resident based on the following:

1. Stated reasons why the intervention is necessary and why less restrictive alternatives are ineffective or inappropriate.

2. The behaviors needing modification.

3. The behavior outcomes desired.

4. The amount of time in each day and length of time in days or months the resident is expected to remain in the locked unit.

5. The time period for which the informed consent is effective.

6. The right to withdraw informed consent at any time verbally or in writing and possible consequences for the center and resident if consent is withdrawn.

(c) "Locked unit" means a ward or wing designated as a protective environment in which treatment and services are provided and which is secured by means of a key lock in a manner that prevents residents from leaving the unit at will. A facility locked for purposes of external security is not a locked unit provided that residents may exit at will.

(d) "Emergency safety intervention" means that a staff member physically intervenes with a resident when the resident's behavior presents an imminent danger of harm to self or others and physical restraint or physically enforced separation is necessary to contain the risk and keep the resident and others safe.

(e) "Physically enforced separation" means that a resident is temporarily physically removed to a time-out room or area including, where applicable, a locked unit. "Physically enforced separation" does not include sending a resident on the resident's own volition to the resident's room or another area for a cooling off period as part of a de-escalation technique.

(f) "Physical hold restraint" means that a resident is temporarily physically restrained by a staff member.

(g) "Time-out room" means a designated room used for temporarily holding a resident who is in physically enforced separation from other residents.

(2)   Monitor and review responsibility.

(a) A center shall assign to a professional staff member the responsibility to monitor and review, on an ongoing basis, the use of all center behavior management measures identified under par. (b) for appropriateness and consistency.

(b) Monitoring and review shall cover violation of house rules and their resulting consequences, the use of physical hold restraint and physically enforced separation in emergency safety intervention, the use of a locked unit when used to facilitate a resident's treatment plan under sub. (7) (a) 3. , and all related center policies and procedures.

(3)   Conduct of residents. A center shall have written policies and procedures covering the conduct expected of residents. The policies and procedures shall do all of the following:

(a) Promote the growth, development and independence of residents.

(b) Address the extent to which a resident's choice will be accommodated in daily decision making. There shall be an emphasis on self-determination and self-management.

(c) Specify center behavior management techniques and approaches available to change, eliminate or modify the behaviors or conditions identified in the center's program statement and operating plan required under s. DCF 52.41 (1) .

(d) Specify criteria for levels of supervision of activities, including off-grounds activities. These criteria shall be directed at protecting the safety and security of residents, center staff, visitors and the community.

(e) Provide for making a record of a resident's off-grounds activities. The record shall include where the resident will be, duration of the visit, the name, address and phone number of the person responsible for the resident and expected time of the resident's return.

(f) Specify house rules for the residents. The house rules shall include all of the following:

1. A general description of acceptable and unacceptable conduct.

2. Curfew requirements.

3. A resident's individual freedoms when the resident is involved in recreational or school activities away from the center.

4. Consequences for a resident who violates a house rule.

(g) Provide for distribution of the house rules to all staff and to all residents and their parents or guardians.

(4)   Prohibited measures. Center staff may not employ any cruel or humiliating measure such as any of the following:

(a) Physically hitting or harming a resident.

(b) Requiring physical exercise such as running laps or doing push-ups or other activities causing physical discomfort such as squatting or bending, or requiring a resident to repeat physical movements or assigning the resident unduly strenuous physical work.

(c) Verbally abusing, ridiculing or humiliating a resident.

(d) Denying shelter, clothing, bedding, a meal, or a menu item, center program services, emotional support, sleep or entry to the center.

(e) Use of a chemical or physical restraint or physically enforced separation or a time-out room as punishment.

(f) Authorizing or directing another resident to employ behavior management techniques on a resident.

(g) Penalizing a group for an identified group member's misbehavior.

(5)   Emergency safety intervention.

(a) A center staff member may not use any type of physical restraint or physically enforced separation on a resident unless the resident's behavior presents an imminent danger of harm to self or others and physical restraint is necessary to contain the risk and keep the resident and others safe.

(ae) A center staff member shall attempt other feasible alternatives to de-escalate a child and situation before using physical restraint or physically enforced separation.

(am) A center staff member may not use physical restraint or physically enforced separation as disciplinary action, for the convenience of center staff, or for therapeutic purposes.

(as) If physical restraint is necessary under par. (a) , a center staff member may only use the physical restraint in the following manner:

1. With the least amount of force necessary and in the least restrictive manner to manage the imminent danger of harm to self or others.

2. That lasts only for the duration of time that there is an imminent danger of harm to self or others.

3. That does not include any of the following:

a. Any maneuver or technique that does not give adequate attention and care to protection of the resident's head.

b. Any maneuver that places pressure or weight on the resident's chest, lungs, sternum, diaphragm, back, or abdomen causing chest compression.

c. Any maneuver that places pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the resident's head or neck, or that otherwise obstructs or restricts the circulation or blood or obstructs an airway, such as straddling or sitting on the resident's torso.

d. Any type of choke hold.

e. Any technique that uses pain inducement to obtain compliance or control, including punching, hitting, hyperextension of joints, or extended use of pressure points for pain compliance.

f. Any technique that involves pushing on or into a resident's mouth, nose, or eyes, or covering the resident's face or body with anything, including soft objects, such as pillows, washcloths, blankets, and bedding.

4. Notwithstanding subd. 3. f. , if a resident is biting himself or herself or other persons, a center staff member may use a finger in a vibrating motion to stimulate the resident's upper lip and cause the resident's mouth to open and may lean into the bite with the least amount of force necessary to open the resident's jaw.

(b) Use of physically enforced separation shall meet the following additional conditions:

1. The staff member using physically enforced separation of a resident shall review need for continued use every 10 minutes while the resident is in physically enforced separation and shall log the time of each review and the emotional status of the resident.

2. Except as otherwise provided for a locked unit under sub. (7) (a) 2. b. , initial use of physically enforced separation may not extend for more than one hour without authorization from the center director or a professional staff person designated by the center director.

3. Except as otherwise provided for a locked unit under sub. (7) (a) 2. b. , if a resident is authorized under subd. 2. to be in physically enforced separation for more than one hour and the physically enforced separation lasts for more than 2 hours, or if the resident experiences multiple episodes in a day which prompt use of physically enforced separation for a cumulative period of more than 2 hours during the day, center staff shall consider the need to arrange another more appropriate placement for the resident.

4. Physical hold restraint on a resident shall not be used to circumvent the requirement of the one hour limit for using a time-out room or a locked unit.

5. A resident may be kept in physically enforced separation only by means of one of the following:

a. A time-out room where the door is latched by positive pressure applied by a staff member's hand without which the latch would spring back allowing the door to open of its own accord.

b. A time-out room where the staff member holds the door to the time-out room shut.

c. A time-out room where the staff member is in a position in the doorway to prevent the resident's leaving.

d. A staff member is in a position to prevent a resident from leaving a designated area.

e. A time-out room which does not use a key lock, pad lock or other lock of similar design and has a type of lock such as a dead bolt lock, magnetic door lock or lock which only requires the turn of a knob to unlock the door, where a staff member is located next to the time-out room door and has the means to unlock the door immediately, if necessary, and that otherwise meets the requirements of this section and chs. SPS 361 to 366 , the Wisconsin Commercial Building Code.

f. In a locked unit that otherwise meets the requirements of this section and the provisions for use of locked units for emergency safety intervention under sub. (7) (a) 2.

6. A resident placed in a time-out room shall be under supervision and shall be free from materials in the room which could represent a hazard to the resident or to others. A time-out room may hold only one resident at a time.

7. A time-out room shall have adequate ventilation and, if there is a door, a shatter-proof observation window on or adjacent to the door. The window's location shall allow for observation of all parts of the room. The room's location shall be within hearing or call to a living area or other area of activity. The time-out room shall have at least 48 square feet of floor space with a ceiling height of not less than 8 feet and a width of at least 6 feet. A time-out room may not include a box or other compartment that represents a stand alone unit within the facility. The time-out room shall be an architectural or permanent part of the building structure.

8. Physically enforced separation in a time-out room may not be used as a substitute for supervision of a resident who is at risk of running away.

(6)   Emergency safety intervention incident reports.

(a) For each incident where physical hold restraint or physically enforced separation of a resident was necessary, the staff person on duty shall document in an incident report the following:

1. The resident's name, age and sex.

2. A description of the incident.

3. The date, time, and location of the incident and methods used to address the resident's behavior, including duration of each emergency safety intervention episode.

4. Results achieved from methods used to address resident behavior.

5. The name of each staff member involved in using the technique or approach with the resident at the time of the incident or when the incident was discovered.

6. Injuries received by either the resident or a staff member in using physically enforced separation or physical hold restraint, how the injuries happened and any medical care provided.

(b) In each building housing residents, center staff shall maintain a log of written reports of incidents involving residents. The report of an incident shall include at least the information under par. (a) 1. to 3.

(c) Resident care staff at the beginning of each shift shall be informed of or review incident reports occurring since their last shift. A copy of each incident report concerning a resident shall be placed in the resident's treatment record.

(7)   Use of locked units.

(a) Conditions for use. No resident may be placed in a locked unit unless the center has first obtained department approval to operate a locked unit, the locked unit meets the requirements of this subsection and one of the following applies:

1. Use of a locked unit is ordered by a physician, to protect the health of the resident or other residents.

2. Use of a locked unit is for purposes of ensuring physically enforced separation when intervening in an emergency safety situation involving the resident. Use of a locked unit to deal with an emergency safety situation may take place provided that the following conditions are met:

a. Use is as a emergency safety intervention physically enforced separation under sub. (5) .

b. Use of a locked unit for emergency safety intervention physically enforced separation may not extend beyond one hour except with written authorization from a physician, a psychologist licensed under ch. 455 , Stats. , or an independent clinical social worker certified under s. 457.08 (4) , Stats. After review of the resident's condition, new written orders, where necessary, may be issued for up to 24 hours. The resident shall be released from the physically enforced separation as quickly as possible. In this subdivision paragraph, "as quickly as possible" means as soon as the resident is calm and no longer a danger to self or others.

c. Use is followed by a review of the need for development of goals and objectives in the resident's treatment plan to govern the use of locked unit physically enforced separation or to minimize or eliminate its need.

3. Use of a locked unit is part of a behavior management and control program described in the resident's treatment plan provided that the following conditions are met:

a. The resident exhibits or recently has exhibited severely aggressive or destructive behaviors that place the resident or others in real or imminent danger and the lack of the locked unit prevents treatment staff from being able to treat the resident.

b. A physician, a psychologist licensed under ch. 455 , Stats. , or an independent clinical social worker certified under s. 457.08 (4) , Stats., who is knowledgeable about contemporary use of locked unit treatment intervention gives written approval included in the resident's treatment record for its use.

c. The goals, objectives and approaches in the resident's treatment plan support its use. Goals and objectives shall be directed at reducing or eliminating the need for use of a locked unit.

d. The parent or guardian and legal custodian of the resident if a minor, gives informed consent in writing to the use of a locked unit or the locked unit intervention is ordered by a court or other lawful authority.

e. The resident has no known medical or mental health condition which would place the resident at risk of harm from being placed in a locked unit as evidenced by a statement from a physician.

(b) Record. The center shall maintain a written record of the following information on locked unit use under par. (a) 3, in the resident's treatment record:

1. The name and age of the resident.

2. The date or dates the resident is in a locked unit and the length of time each day.

3. At least weekly assessment for continued need for locked unit use.

(c) Supervision. Appropriately trained staff shall directly supervise use of a locked unit. Appropriately trained staff are staff who have received the training under s. DCF 52.12 (5) (b) 4. and (c) .

(d) Center locked unit policies and procedures. A center with a locked unit shall have written policies and procedures that include all of the following:

1. Except as provided in this subsection, no resident may be housed in a locked unit.

2. A resident may be in a locked unit only if there is a written informed consent document signed by the resident's parent or guardian and legal custodian or by an order of a court or other lawful authority or as provided under subd. 5. A copy of the informed consent document, court order or document from another lawful authority shall be filed in the resident's treatment record.

3. Parent or guardian and legal custodian written informed consent to placement of a resident in a locked unit shall be effective for no more than 45 days from the date of the consent and may be withdrawn sooner unless otherwise specified in a court order or by another lawful authority. Parent or guardian and legal custodian written informed consent for continued use of a locked unit may be renewed for 30 day periods except as otherwise specified in a court order or by another lawful authority. Each renewal of informed consent shall be through a separate written informed consent document.

4. Except as otherwise specified in a court order or by another lawful authority, the parent or guardian or the legal custodian may withdraw his or her written informed consent to the resident being placed in a locked unit at any time, orally or in writing. The resident shall be transferred to an unlocked unit promptly following withdrawal of informed consent.

5. In an emergency such as when a resident runs away, is being held for movement to secure detention until police arrive or has attempted suicide, the resident may be placed in a locked unit without parent or guardian or legal custodian consent. The parent or guardian and legal custodian shall be notified as soon as possible and written authorization for continued use of the locked unit shall be obtained from the parent or guardian and legal custodian within 24 hours. No resident kept in a locked unit under this subdivision may be kept in the locked unit for more than an additional 72 hours unless a written informed consent document signed by the parent or guardian and legal custodian authorizing continued locked unit use is obtained.

6. Prior to use of a locked unit, written approval to lock exit access doors of the unit is obtained from the Wisconsin department of safety and professional services.

7. All staff members supervising residents in a locked unit shall have the means to unlock the unit immediately if this is necessary.

8. A locked unit shall be free of furnishings that could be used by a resident in a harmful way and shall have adequate ventilation.

9. A center shall provide in each locked unit one resident care worker with no assigned responsibilities other than direct supervision of the residents. During hours when residents are awake there shall be one resident care worker for every 4 residents and one resident care worker for every 6 residents during sleeping hours. Staff shall be present in the locked unit with residents and shall have the means to immediately summon additional staff.

(8)   Behavior modification and control measures.

(a) A center may not use intrusive and restrictive behavior management techniques such as behavior-modifying drugs or other forms of physical restraint as defined under s. 48.599 (1r) , Stats., not identified in this section unless the center receives approval for their use from the department and where applicable, procedures in accordance with provisions found in this chapter are followed.

(b) Use of locked rooms for physically enforced separation of residents other than as provided under sub. (5) for emergency safety intervention is prohibited.

(c) A center may not use on a resident any aversive measure that is painful or discomforting to a resident or any measures that are dangerous or potentially injurious to a resident.

(9)   Absence of residents without permission. A center shall have written policies and procedures for notifying the appropriate local law enforcement agency that a resident has left the center without permission or fails to return to the center after an approved leave. The procedures shall specify all of the following:

(a) How the determination is made that a resident is missing.

(b) The name of the local law enforcement agency and the name of the agency, if different, that is to be notified in order for it to file a missing person report with the crime information bureau of the Wisconsin department of justice.

(c) The name of the staff member who will promptly notify the law enforcement agency identified under par. (b) of the resident's absence, as well as the resident's parent or guardian and legal custodian, if any, and the placing person or agency, if not the same.

(d) Notification of the department's interstate compact office at least within 48 hours of an out-of-state resident's absence.

History: Cr. Register, February, 2000, No. 530 , eff. 9-1-00; CR 04-040 : am. (5) (b) 5. e. and (7) (d) 6. Register December 2004 No. 588 , eff. 1-1-05; corrections in (3) (c) and (7) (c) made under s. 13.92 (4) (b) 7. , Stats., Register November 2008 No. 635 ; EmR1106 : emerg. r. and recr. (1) (d), (5) (a), cr. (5) (ae), (am), (as), (b) 8., eff. 9-16-11; CR 11-026 : r. and recr. (1) (d), (5) (a), am. (2) (b), (5) (b) 5. f., (6) (title), (a) 3., (7) (a) 2. (intro.), a., b., (8) (b), cr. (5) (ae), (am), (as), (b) 8., r. (5) (b) (title) Register December 2011 No. 672 , eff. 1-1-12; correction in (5) (b) 5. e., (7) (d) 6. made under s. 13.92 (4) (b) 6. , 7. , Stats., Register December 2011 No. 672 , eff. 1-1-12; correction in (8) made under s. 13.92 (4) (b) 7. , Stats., Register October 2015 No. 718 .

Note

There is a difference between a patient right and a privilege. Deprivation of a privilege such as watching television, playing video games, going to the movies or involvement in some other recreational activity may be used as a disciplinary measure. Microsoft Windows NT 6.1.7601 Service Pack 1 For notification of Wisconsin's Interstate Compact Office, phone: [phone]. Microsoft Windows NT 6.1.7601 Service Pack 1