Safer restraints in group homes?
Posted on Thu,
Apr. 28, 2005
Proposed rules would ban workers from sitting on children
South Carolina is poised to ban group home workers from restraining children by putting pressure on their chest or abdomen -- a maneuver that killed two Carolina children in two years.
Shirley Arciszewski, 12, died after a worker restrained her at a Charlotte group home for mentally ill children in September. An autopsy blamed asphyxia caused by an adult lying on her.
In 2003, a 220-pound worker at a group home outside Charleston lay across 9-year-old Jamal Odum's back for seven minutes. He also died of asphyxia.
Neither North Carolina nor South Carolina explicitly bars workers from lying or sitting on children to control them.
"These are extremely dangerous techniques," said Rochelle Caton, an attorney with S.C. Protection and Advocacy for People with Disabilities in Columbia. "Even if you are properly trained."
Roughly 6,000 children enter group homes and similar institutions each year in the Carolinas because of emotional and behavioral problems their families can't handle. Physical restraints aren't rare; both states allow workers to hold children to keep them from hurting themselves or others.
After Jamal's death, three workers at New Hope For Children in Jedburg, S.C., were arrested. One was charged with homicide by child abuse and two others faced lesser offenses.The charges were dropped in February after prosecutors saw the home's training manual. It included a photograph showing a worker lying on top of a person to restrain him, said Berkeley County Deputy Solicitor Blair Jennings.
"Clearly, what they did wasn't right," Jennings said. "But we weren't going to be able to prove he acted recklessly with the training he received."
Jay Orvin, president and CEO of the home's parent corporation, said New Hope Treatment Centers voluntarily removed the photo after Jamal's death because of concerns that it "might be confusing."
He said it did not depict a worker laying across a child, but showed a child face-down on the floor with a worker "forming a bridge" over the child's body and holding his arms.
The manual did not endorse restraining children by putting pressure on their torso, Orvin said.
"There was never, ever, ever anything in our manuals that said it was OK to do it that way," he said.
What would be banned?
Laying across a child's back or chest would be banned outright under the new rules the S.C. Department of Health and Human Services is considering, according to a draft obtained by the Observer.
The prohibited practices would also include causing pain to force compliance, sitting on or straddling any part of the body, or using drugs or mechanical devices to restrain a child.
The 11-page proposed "Emergency Safety Interventions" policy, which also covers the use of locked seclusion rooms, requires homes to notify a child's parents or guardian as soon as possible after performing a restraint.
They also mandate that workers learn de-escalation techniques and understand the risk of so-called positional asphyxia, which can occur when body position restricts a person's ability to breathe. Under the proposal, facilities would need to create a plan for reducing the use of restraints.
The new regulations would affect roughly 1,800 children in group homes and similar institutions across South Carolina whose treatment is paid for by state and federal Medicaid dollars.
States set the rules for providers who treat kids on Medicaid, the government's health insurance plan for the poor and disabled. S.C. officials said Jamal's death was among the reasons they decided to tighten their standards.
State clinicians who regularly visited the homes also urged the agency to adopt better guidelines, said Jeanne Carlton, an HHS supervisor.
The use of restraints has undergone scrutiny in recent years after deaths at facilities across the country, said Caton, the advocate.
Medications or health conditions such as asthma make some holds that appear safe dangerous for children, she said. Children who have suffered physical or sexual abuse at home -- as many in group homes have -- find restraints particularly hard to endure, she said.
"When you take a child who has been sexually abused and hold them down, you are retraumatizing them," she said.
N.C. and beyond
North Carolina doesn't explicitly ban restraints that compress the chest, or require training in the dangers of such holds. About 4,000 children live in the state's group homes.But N.C. rules say restraints can't be used in a way that causes harm or abuse. And Joan Kaye, an N.C. Division of Mental Health team leader, said regulators review all training programs that group homes use.
"We know that that's an unsafe practice," she said. "We would definitely not be approving any training program that had that in it."
Shirley was not the only N.C. child to die after a restraint. In 1999, 9-year-old Timithy Thomas suffocated at a Banner Elk charter school on the grounds of a group home during a "basket hold." In that restraint, a worker stands behind a child, crosses his arms over the child's chest and eases him to the ground.
S.C. health and human services staff are reviewing comments from providers and advocates about the draft, said Sheila Mills, an HHS bureau chief. It could still change.
Penalties for breaking the restraint rules would resemble those for breaking other Medicaid standards, she said. Fines are set on a case-by-case basis, she said.
When that review is done, agency administrator Robert Kerr will decide whether to adopt the new standards. The decision should be made by June 30, officials said.
Proposed Prohibitions for S.C. Group Homes
Pain inducement to obtain compliance
Hyperextension of joints
Use of seclusion rooms that do not meet agency, licensing or accreditation standards
The use of extra medications to control an individual's behavior or restrict his or her freedom
Use of restraint when child would be medically compromised
Restraint and seclusion used simultaneously with mechanical restraint devices
Pressure or weight on the chest, lungs, sternum, diaphragm, back or abdomen, causing chest compression
Straddling or sitting on any part of the body, or any maneuver that places pressure, weight or leverage on the neck or throat, on any artery, or on the back of the child's head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway
Any type of choking, and any type of neck or head hold
Any technique that involves pushing on or into the child's mouth, nose, eyes or any part of the face, or covering the face or body with anything, including soft objects such as pillows
Any maneuver that involves punching, hitting, poking, pinching or shoving