On 5/16/23, resident became very dysregulated in the classroom and moved into the hallway. Once in the hallway, resident began picking at self-harm spots on her arms. Staff tried to stop the self-harming by blocking attempts and called the nurse for support. The nurse then showed up and attempted to redirect. Resident then attempted to hit her head on the wall with enough force to cause injury. Due to concerns for the resident’s safety, the nurse called for a physical hold and contacted the provider. I reviewed the current oral medication with the provider. After explaining the situation to the provider, the nurse returned to restraint. Resident appeared relaxed and calm. The restraint was ended. After the restraint, resident willingly received a one-time PRN medication to assist with continuation of emotional regulation, and this medication was well tolerated. She was compliant and seemed calm enough to rejoin the milieu. A physical assessment following the restraint found no injuries from this incident and only a minor exasperation of the existing superficial abrasion on residents’ forehead. The provider also made adjustments to resident’s current medication regimen for mood stability. Resident will be on a safety plan including constant line-of-sight monitoring for a period to be determined by the therapist.
