EUMR addendum

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This form needs to be filled out when there is a GER completed in Therap after a manual restraint. Please fill out this form completely and then submit. Your supervisor will then attach it to the GER form.

EUMR form

Name of the Person Served

Date and Time of the incident

List all people who were present before and during the incident, leading up to the manual restraint or 911 call.

Describe the physical and social environment leading up to the behavior. What was happening during the day leading up to the triggering situation or the event?

What time did you start the de-escalation efforts?

Explain how you attempted to de-escalate before manual restraint was implemented

How long did you try the de-escalation efforts before restraining the person?

What did the person specifically do that created the need for the manual restraint?

Describe the mental, physical, and emotional condition of the person who was restrained-- leading up to, during, and following the manual restraint

Describe the mental, physical, and emotional condition of other persons involved in the incident leading up to, during, and following the manual restraint

Name of the staff who monitored the person during the restraint.

Did the person exhibit pain or difficulty breathing during the restraint?

Yes

What was done to fix the pain or difficulty breathing?

Was there an attempt to lessen or reduce the restraint every 15 minutes?

Yes

NA-- restraint was less than 15 min.

Did the person who was restrained get injured before or during the restraint?

Yes

Describe the injury and the care that was needed.

Did anyone else (including staff) get injured before or during the restraint?

Yes

Describe the injury and the care that was needed.

Describe the mood and the actions of the person after they were released from the restraint.

Was a debriefing done with the staff?

Yes

Was a debriefing done with the person who was restrained?

Yes

When is a debriefing scheduled to occur?

EUMR Addendum

Orion Associates

820 Lilac Drive N.

Golden Valley, MN 55422