6.5 Ycs Physical Control/Separation Report

6.5 YCS PHYSICAL CONTROL/SEPARATION REPORT

Program/School: ______Client:______

Date of Incident:______Time of Incident:______Shift: _____AM____PM____Overnight

Person Writing Report:______Date:______

Witness(es):______Date:______

SECTION A - Type of Incident (Check all that apply)

Aggression toward
___Staff ___Resident / Disagreement with Staff / Run/Walk-Away Attempt / Theft / Terroristic Threat
Alleged Emotional Abuse
___Staff ___Guardian / Emotional Distress / Run/Walk-Away / Property Damage / Fire Starting
Alleged Physical Abuse
___Staff ___Guardian / Injury- Accidental / Medical Hospitalization / Contraband / Felony
Alleged Sexual Abuse
___Staff ___Guardian / Sexual Contact Between Residents / Client became out of control / Resident Fighting / Homicide Attempt
Assault Against
___Staff ___Resident / Inappropriate Physical Exposure / Psych. Hospitalization / Drug Possession/Sale / Homicide
Refusing A Directive / Self Abuse / Suicidal Talk / Drug/Alcohol Use / Death
Disagreement between Peers / Suicide Attempt / Suicide / Other: ______

Location Where Incident Took Place (Check all that apply)

OFF GROUNDS / RESIDENCE
In Vehicle / Out With Volunteer / Bathroom / Hallway / Outdoors
On Activity / Outdoors / Bedroom / Kitchen / Public Space
At Home / Other / Dining Room / Lounge / Other

SECTION B - Type of Intervention (Check all that apply)

□ Physical ControlTime started:______Time ended:______

□ EscortTime started:______Time ended:______

□ Separation/Quiet TimeTime started:______Time ended:______

(Staff member observing child every 10 minutes)□ Total time less than 10 minutes □ Total time greater than 10 minutes

* if physical control time is greater than 30 minutes obtain order from physician/Advanced Practice Nurse

Check techniques used during Physical Control, Escort or Separation:

CPI: □ Children’s Control Position □ Team Control Position □ Transport Technique □ Interim Control

HWC: □ Primary Restraint Tech. □ Modified Primary Restraint Tech. □ 2-Person Escort Tech. □ 2-Person Take Down

Check preventive CPI techniques used: □ Supportive Staff Response □ Directive Approach □ Therapeutic Rapport

(Empathic/Active Listening) (Setting Limits/PNP Consequence)

In order to release the child from the restraint, the child was: □Calm □ Breathing level returned to normal

□Body tension decreased □Verbally compliant

Did injury occur to child during physical control or separation from group? □ NO □ YES

If no injuries noted – nurse to evaluate child by next business day.
If injury noted – nurse to evaluate within 1 hour of physical control

Number of times this child has been physically controlled over the past 12 hours:______

Name of Administrator Notified:______Time Notified:______

SECTION C - Notification (Check all that apply and fill in name of person contacted, time and date)

TITLE / NAME / TIME / DATE
Supervisor
Administrator.
Clinician.
Nurse
Psychiatrist/APN-OnCall
Psychiatrist/APN-Regular
Parent/Guardian
DYFS Worker
Other

SECTION D - Narrative Section (Please attach additional sheets if necessary)

TYPE OF INCIDENT: Describe in detail any areas checked off in SECTION A on the reverse side:

Child checked for injuries and no injuries noted – nurse to evaluate child by next business day.
Child checked for injuries and injury noted – nurse to evaluate within 1 hour of physical control *notify on-call nurse if necessary

______

(Print Name)(Title)(Date) (Signature)

POSSIBLE CAUSE/PRECIPITATING FACTORS/RATIONALE FOR PHYSICAL CONTROL:

______

(Print Name)(Title)(Date) (Signature)

NURSING SUMMARY: (To be completed by Nurse)

Did an injury occur to the child? □ NO □ YES

Treatment Team Psychiatrist/APN Notified:______Date:______Time:______

Parent/Guardian Notified (If immediate notification is required: □ NO □ YES If yes, via: □ letter □phone Date: ______Time: ______

______

(Print Name)(Title)(Date) (Signature)

INTERVENTIONS: Please Check All That Apply:

Nonverbal communication / Restate Directions / Address Alternatives
Provide Verbal Support / Provide Verbal Direction / Stress Reduction Techniques
Redirect client from the situation / Tell-show-do / Positive reinforcement
Remind client of benefits of program compliance / Redirect within the Behavior Management System / CPI (Support-Direct-Isolate)
Referred To/Brought to Nurse / Referred To/Brought to Social Worker / Quiet Time
Other Interventions as based on the client’s treatment plan: ______/ Other Interventions as based on the client’s treatment plan: ______/ Other:

SECTION E - REVIEW/FINAL DISPOSITION OF INCIDENT:(Comments/Recommendations/Follow-Up/Acknowledgement of Physical Control)

SUPERVISOR:(on the shift at the time of the physical control):

______

(Print Name)(Title)(Date) (Signature)

CLINICIAN or BEHAVIORIST:

______

(Print Name)(Title)(Date) (Signature)

ADMINISTRATOR:

______

(Print Name)(Title)(Date) (Signature)

Documents completed in conjunction with this report: □ Clinical Note □Physical Control Order Form□Nursing Assessment

□ Unusual Incident Report (if client is injured) □Staff Debriefing □ 15 minute check (as necessary) □ Client Debriefing

(Revised 6/11)

Partial Day/Shelter Programs

Procedure for obtaining orders for Partial Day Programs

The following process shall be followed regarding the order requirements needed for physical controls. The table below indicates who should be called on what days and times.

IF AN ORDER IS NEEDED / BETWEEN THE HOURS OF: / YOU SHOULD CALL/CONTACT:
Monday through Friday / 9:00am to 5:00 pm / The child’s regular treatment team Psychiatrist/APN

*For Partial Day Programs/Shelter Facilities an orders is to be obtained for a physical control only if it length of time is 30 minutes or greater.

Procedure for obtaining orders for Shelter programs

The following process shall be followed regarding the order requirements needed for physical controls. The table below indicates who should be called on what days and times.

IF AN ORDER IS NEEDED / BETWEEN THE HOURS OF: / YOU SHOULD CALL/CONTACT:
Monday through Friday / 9:00am to 5:00 pm / The child’s regular treatment team Psychiatrist/APN
Monday through Friday / 5:00pm-9:00am / Utilize Psychiatrist/APN On-Call Schedule
Saturday through Sunday / All Hours / Utilize Psychiatrist/APN On-Call Schedule

*For Partial Day Programs/Shelter Facilities an orders is to be obtained for a physical control only if it length of time is 30 minutes or greater.

Related Documents:

Physical Control Order Form

Process for obtaining nursing assessement.

The program nurse or on-call nurse will be notified of a Physical Control immediately. The client will be checked immediately for any injuries by staff and give a report to the nurse. If injuries are noted, the program nurse or on-call nurse will perform a post physical control nursing assessment within 1 hour of physical control. If no injuries are noted, the program nurse or on-call nurse will complete the post physical control nursing assessement no later than by the next business day of physical control.

Note the below on call nurse schedule(site to complete to indicate program nurse and on-call nurse; This document is to be accessible to all staff)

MONDAY – FRIDAY BETWEEN THE HOURS OF: / YOU SHOULD CALL/CONTACT:
Program Nurse on site
On-call Nurse:

if the program nurse is out of building/sick/on vacation the on-call nurse is to be notified in advance if possible of program nurse’s absence and will be utilized during that time for any physical controls.

Related Documents:

Physical Control/Seraration Report

Post Physical Control Nursing Assessment Form