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2.0 Supporting People with Challenging Behaviour (continued)

Use of Secure Isolation or Confinement Time-Out Rooms

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policies and procedures”, and section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that, where secure isolation or confinement time out is recommended to be used to address a person’s challenging behaviour as part of their behaviour support plan, the following performance standards and measures are adopted:

  • A service agency shall ensure that its written policies and procedures on the use of a secure isolation or time-out room address the following:
    • Stages of interval monitoring;
    • Duration of time that a person may spend in secure isolation or confinement time-out, any extension periods, and the total/maximum amount of time that a person may spend in secure isolation or confinement time-out;
    • Protocols regarding continuous observation and monitoring of a person who is in the secure isolation or confinement time-out room;
    • Regular record keeping(e.g., every fifteen minutes) of secure isolation or confinement time-out room use for each person with a developmental disability who has challenging behaviour, and trend analysis for each person; and
    • Notification of key agency staff that the secure isolation or confinement time-out room has been used, and regular report-backs to key clinicians overseeing the person’s behaviour support plan.

  • A service agency will ensure that the physical space of the secure isolation or confinement time-out room:
    • Is not used as a bedroom for a person with a developmental disability who has challenging behaviour;
    • Is of an adequate size for the person with a developmental disability who has challenging behaviour;
    • Does not contain any objects that could be used by the person to cause injury or damage to him/herself or others (i.e., staff who may enter the room);
    • Is a safe area, with modifications (as appropriate) that would protect the person from self-injury;
    • Has means to allow for constant observation and monitoring of the person by service agency staff(e.g., a window, a video-camera);
    • Is adequately illuminated so that the person inside the room may be seen; and
    • Is adequately ventilated and heated/cooled.
  • A service agency shall ensure that its fire escape plan includes provisions for escape from the secure isolation or confinement time-out room, in the event of an emergency.
  • If the secure isolation or confinement time-out room has a lock on the door to prevent the person from leaving the room, the service agency will ensure that the lock can be easily released from the outside in an emergency. 

Use of Mechanical Restraint

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that where a mechanical restraint is recommended to be used to address a person’s challenging behaviour as part of their behaviour support plan, any apparatus or device used as part of a mechanical restraint meets all of the following standards:

  • It is designed and manufactured for use as a mechanical restraint;
  • It is appropriate for use with the individual (e.g., the size of the device or apparatus is appropriate to the size and weight of the person);
  • It is purchased from a company that is dedicated to manufacturing such devices;
  • It is checked by agency staff to ensure that it is in good working order at all times; and
  • It is maintained in good repair by the manufacturer or by a person or organization recommended by the manufacturer.

Use of Prescribed Medication

As previously noted, the Primary Care of Adults with Developmental Disabilities: Canadian Consensus Guidelines6 and the Tools for Primary Care Providers and Tools for Caregivers7, are valuable resources that may be of assistance to service agencies and clinicians who support adults with a developmental disability, as well as their families or caregivers. Both documents contain specific sections on the use of prescribed medication to address challenging behaviour.

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policiesand procedures”, and section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that where prescribed medication is recommended to be used to address a person’s challenging behaviour, as part of their behaviour support plan, a one-time visit to a physician, or a visit to a hospital emergency room, there is a protocol for the use of prescribed medication administered on a pro re nata (PRN) (as needed) basis only, on advice of the prescribing clinician.  PRNs are not to be administered:

  • Excessively, beyond the recommended dosage;
  • As a punishment for the person’s behaviour, a mistake or wrong-doing;
  • For convenience, to make it easier for staff to support the person; and
  • As a substitute for meaningful supports.

A service agency shall ensure that all medication prescribed to the person with a developmental disability who has challenging behaviour is reviewed by the prescribing physician, and is included in the regular review of the individual’s behaviour support plan.

Procedures Not Permitted

In addition to the definitions and examples of behaviour interventions set out in section 15, “Application and definitions”, of Ontario Regulation 299/10 (the quality assurance measures regulation), the following practices are never to be used by a service agency in addressing the challenging behaviour of a person with a developmental disability:

  • Mistreatment of the person – mistreatment could include but is not necessarily limited to: physical or corporal punishment, such as punching, slapping, or pulling hair; abandonment or segregation, rough handling, ridicule, humiliation, or name-calling;
  • Noxious stimulus – people should not be subjected to harmful or offensive odours or liquids as a form of punishment or discipline, such as a spray of lemon juice, drops of Tabasco sauce, or pepper; and/or
  • Deprivation of basic human needs – people should not be deprived of basic human needs, including food, adequate clothing, and adequate heat and cooling; access to health care, suitable shelter and safety; or reasonable access to family members (if desired by the individual), as part of a behaviour intervention strategy.

Definition:

“Segregation” is the act of setting a person apart from others in the general vicinity, in the scenario considered above, for the purposes of punishing the person.  It is not considered part of the definition of “secure isolation or confinement time-out”.  As with the definition of “secure isolation or confinement time-out, segregation does not refer to a space that a person may use to “cool down” when he/she feels anxious or angry, and where the person may leave freely, or an apartment where the person may live on his/her own.

Monitoring

This standard is further to section 20(3), “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that there are protocols in place that must be followed in monitoring and assessing the condition of the person with a developmental disability during the use of intrusive behaviour intervention. These protocols may differ, depending on the type of intrusive intervention, and on the individual and his/her needs.

A service agency or the clinician who oversees the behaviour support plan must ensure that there are safeguards to prevent misuse of intrusive behaviour intervention.

A service agency shall have a means to record and track intrusive behaviour intervention procedures for the purpose of review and analysis.

When applicable, a service agency shall file a serious occurrence report with the Ministry of Community and Social Services (e.g., in an instance where a person becomes seriously injured, or an instance where allegations of mistreatment emerge).

Notification of the Use of Behaviour Intervention

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policies and procedures”, of Ontario Regulation 299/10, a service agency shall have policies and procedures regarding the notification of persons (a “contact person”) acting on behalf of the individual with a developmental disability who has challenging behaviour .  The policies and procedures shall consider an individual’s ability to provide consent regarding notification, and shall address:

  • Whether and/or under what circumstances the agency would notify the contact person of the use of intrusive behaviour intervention with the individual, where the intrusive behaviour intervention is outlined in the individual’s behaviour support plan;
  • Regular updates on the use of intrusive behaviour intervention with the individual to the contact person, when the behaviour support plan does not specify that each use of intrusive behaviour intervention be communicated to the contact person;and
  • Notifying the contact person of the use of a physical restraint with the individual, in a crisis situation.

6 Sullivan WF, Berg JM, Bradley E, Cheetham T, Denton R, Heng J, Hennen B, Joyce D, Kelly M, Korossy M, Lunsky Y, and McMillan S.  Consensus guidelines for primary health care of adults with developmental disabilities. Canadian Family Physician 2011; 57: 541-53. (accessed November 2, 2016).

7 Developmental Disabilities Primary Care Initiative.   Available from: http://www.surreyplace.on.ca/resources-publications/primary-care/ (accessed November 2, 2016).