Within 24 hours of applying four-point, five-point restraint, or seclusion, all involved staff at a mental health (MH) provider must conduct a post-event analysis chaired by the nursing supervisor, designee, or risk manager. The analysis must cover the precipitating emergency, alternative techniques that could have prevented the intervention, procedures to prevent recurrence, and outcomes including any injuries. Findings and recommendations must be documented consistent with peer review and continuous quality improvement practices.
View official source509 POST EVENT ANALYSIS OF THE USE OF FOUR-POINT AND FIVE-POINT RESTRAINT OR SECLUSION 509.1 All staff involved in the use of restraint or seclusion shall, within twenty-four (24) hours of the application of restraint or seclusion, conduct a post event analysis among themselves regarding the events surrounding the emergency that required the use of restraints or seclusion. The post event analysis is separate from the more formal treatment team debriefing described in §§ 510 that is conducted by the consumer's team. 509.2 The MH provider's nursing supervisor, the nursing supervisor's designee or risk manager shall chair the post event analysis meeting. The post event analysis shall, at a minimum, include a discussion of: (a) The emergency that required the use of restraints or placement in seclusion, including a discussion of the precipitating factors that led up to the use of restraint or placement in seclusion; (b) Alternative techniques that might have prevented the use of the restraint or seclusion; (c) The procedures, if any, that staff are to implement to prevent any recurrence of the use of restraints or seclusion; and (d) The outcome of the intervention, including any injuries that may have resulted from the use of restraints or seclusion. 509.3 Issues, concerns, and recommendations from the post event analysis meeting, shall be documented, by the person chairing the meeting, in a manner consistent with standard peer review and continuous quality improvement practices. SOURCE: Emergency and Proposed Rulemaking published at 51 DCR 8691 (September 3, 2004)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 51 DCR 11863 (December 31, 2004)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 52 DCR 5957 (June 24, 2005)[EXPIRED]; as amended by Final Rulemaking published at 52 DCR 7229 (August 5, 2005). District of Columbia Municipal Regulations Mental Health 22-A DCMR § 509