Restrictive Intervention Application (RIA) Data Form

(1)

Restrictive Intervention Application (RIA) Data Form

All Fields Required

INDIVIDUAL INFORMATION

1. Individual’s Name & ID: FIRST

LAST __________________________

HERITAGE ID#

EVENT INFORMATION

2. DATE _________ TIME EVENT STARTED _ TIME EVENT ENDED _______

_________________________________________________________________________________________________

PROGRAM INFORMATION

3. Program/Site:

_____________________________________

4. Program Address: _____________________________________

5. Program Type:

 Individualized Residential Alternative (IRA)  Day Habilitation-Site Based

 Employment/Work Site  Community Programs - Specify Program

________________

6. Location:

 only one location unless additional interventions result in other locations used.

If multiple locations are used, check “Other” and explain.

7. Briefly Describe Antecedents, Behavior(s) and Consequences of Behavior:

 Attic  Elevator  Laundry Room  Parking Lot  Treatment Room

 Back Yard  Foyer  Living Room  Program Room  Vehicle

 Basement  Front Yard  Loading Dock  Recreation Area  Work Area

 Bathroom  Garage  Lunch Room  Sidewalk

 Bedroom  Hallway  Off Facility Property  Staircase

 Dining Room  Kitchen  Office  Swimming Pool

 Other: ________________________________________________________________________________ 2643 Main Street, Buffalo, NY 14214

(2)

8. Behavior:

 all that apply

9. Verbal and Non-Verbal Interventions:

10. Non-Restrictive Physical Interventions:

11. Non-Restrictive Physical Interventions:

list all non-restrictive physical interventions used  all that apply  Part of Behavior Plan  Emergency Basis

If Restrictive Physical Interventions Were Used Continue with # 12.

If Restrictive Physical Interventions Were Not Used, Continue with # 16.

RESTRICTIVE PHYSICAL INTERVENTION INFORMATION

12. IRMA Master Incident Number

(if available/applicable)

:

TABs ID# ________________

13. Select the most Restrictive SCIP-R Technique Used (Check only one):

 One Person Take-Down  Two Person Take Down

 One Person Take-Down to Side Control  Two Person Take-Down to Supine Control

 One Person Take-Down to Seated Control  Two Person Take-Down to Two to Three Person Supine Control  Two to Three Person Supine Control

 Physical Aggression to Others  Self Injurious Behavior

 Physical Aggression to Environment  Breaking Property in Home/Community

 Verbal Abuse/Threats  Stealing

 Leave Without Consent/Supervision  Smearing/Digging Feces  Sexual Contact with Others

 Inappropriate Sexual Behavior (Explain) ____________________________________________________  Other (Explain) ________________________________________________________________________

 Redirection to Another Activity  Touch  Planned Ignoring  Eye Contact  Effective Use of Space  Facial Expressions

 Close Proximity  Body Posture  Access to Preferred Objects

 Ventilation  Understanding  Reminder of Natural Consequences

 Active Listening  Modeling  Positive Language

 Distraction  Humor  Facilitate Relaxation

 Reassurance  One on One (1:1)  Encourage Alternate Strategies

 PRN Medication Utilized (Must Complete Items 21 – 26)

 Touch Control  1 Person Escort  1 Person Escort/Seated

 2 Person Escort  Arm Control  2 Person Escort/Seated

 Standing Wrap  Front Deflection  Bite Release

 Hair Pull Release  Seated Wrap  Block Punch

 1 Person Wrap/Removal  2 Person Wrap/Removal

 Other(Explain) ________________________________________________________________________

INTERVENTION TIME INITIATED TIME

RELEASED

DURATION STAFF INVOLVED INTERVENTION

PART OF BEHAVIOR PLAN?  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No

(3)

14. Restrictive Physical Interventions:

list all restrictive physical interventions used

 all that apply  Part of Behavior Plan  Emergency Basis

If intervention exceeds 20 minutes without a release , a 147 form must be filed in IRMA

INTERVENTION TIME INITIATED TIME

RELEASED

DURATION STAFF INVOLVED INTERVENTION

PART OF BEHAVIOR PLAN?  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No

15. Reason for Physical Intervention:  all that apply

 Harming Others  Harming Self  Person in an unsafe location  Other (explain): Other Reason for Physical Intervention:

__________________________________________________________

MEDICAL INFORMATION

16. Body Check Performed?  Yes

 No

a. If yes, Name of staff person conducting body check:

FIRST LAST ___

b. TITLE:

 Direct Support Professional  Nurse Practitioner (NP)

 Direct Support Professional SUPERVISOR  Registered Nurse (RN)  Residential Manager/House Director  Physician Assistant (PA)

 Classroom Aide/Assistant  Behavior Specialist/Assistant

 Classroom TEACHER  Licensed Psychologist

 Classroom SUPERVISOR  Clinician

 Licensed Practical Nurse (LPN)  Other ______________________________________

c.  If no - What is the reason?  Refused  Unknown  Called 911  Transported to ER

 Emergent Medical Needs Supersedes Body Check

17. Injury: Did Implementing the Restrictive Physical Intervention Result in an Injury to the Individual?

 Yes If yes,  all the injuries from the list below  No

 Abrasion  Redness  CONCUSSION  LACERATION W/SUTURES

 Bruise/Contusion  Scratch  DISLOCATION  LOSS OF CONSCIOUSNESS

 Hematoma  Skin Reaction  FRACTURE  INTERNAL INJURIES

 Laceration without Sutures  Swelling  OTHER (only if it meets the Part 624 definition of an injury) ___________________________________________________

 Puncture  Sprain

(4)

18. Indicate the Injury Location for the Individual by number(s) found on the

a. Front Body Diagram:

b. Back Body Diagram:

24 Hour Body Check

Second Body Check Performed

Date:

Time:

New Findings:

Completed By:

STAFF INFORMATION

19. Please list up to six (6) staff involved in the physical intervention. Use titles from #16.b:

Staff 1:

First Name Last Name Title

Staff 2:

Staff 3:

Staff 4:

Staff 5:

Staff 6:

20. Was Staff Injured as a Result of the Physical Intervention?

 Yes

 No

 Yes, Multiple Staff Injured

Accident & Injury Report must be completed for all staff injuries

.

(5)

MEDICATION ADMINISTRATION INFORMATION  N/A

21. Date Medication Administered: ________________

22a.



PRN Medication



STAT Medication

23a. Medication Name: ________________________Dose: Route: (PO/IM)

(Refer to attached chart for medication name, dose and route.

24a. Usage of Restrictive Intervention:

 all that apply  Part of Behavior Plan  Emergency Basis

25a. Time Medication Administered:

(HH MM)



am



pm

26a. Reason Medication was administered:  all that apply:

 Harming Others  Harming Self  Other (explain): Other Reason for Medication Administered

:

- - -

22b.



PRN Medication



STAT Medication

23b. Medication Name: _______________Dose: Route: (PO/IM) _

24b. Usage of Restrictive Intervention:

 all that apply  Part of Behavior Plan  Emergency Basis

25b. Time Medication Administered:

(HH MM) 

am



pm

26b. Reason Medication was administered:  all that apply:

:

- - -

22c.



PRN Medication



STAT Medication

23c.Medication Name: ________________________Dose: Route: (PO/IM)

24c. Usage of Restrictive Intervention:

 all that apply:  Part of Behavior Plan  Emergency Basis

25c. Time Medication Administered:

(HH MM)



am



pm

26c. Reason Medication was administered:  all that apply:

:

INCIDENT CATEGORY/CLASSIFICATION

27. Select Category/Class of incident

 N/A

 Non-Reportable Incidents/Notable Events

 Reportable Incident ____________________________________  Serious Reportable Incident _____________________________  Allegation of Abuse: ____________________________________

 Mistreatment  Neglect Physical Psychological

28. Name and title of staff completing form:

29. Date Completed: ______________________

F:\Docs\Adminstrative Services\BOB\Online Forms\Word Documents\RIA Form 7-11-2012.docx March 6, 2013

3-20-2018

Restrictive Intervention Application (RIA) Data Form