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Kathy left a comment with some questions that I am going to address in my post today, instead of in the comments. She has some valid questions, and I hope this will help Kathy, as well as anyone else with the same concern, understand why a nursing home and hospital surveyor asks the questions they do and what any facility, whether nursing home or hospital, can do to help reduce restraints. You can see Kathy’s comment at the post titled “Surveying Restraint Regulations in Hospitals or Nursing Homes – Part I“.

Hi Kathy,

CMS doesn’t look for a “diagnosis”, but for the MEDICAL reasons for a restraint. The interpretive guidelines at the restraint regulations in Appendix PP of the SOM (State Operations Manual) gives a lot of guidance and additional thoughts on what you might consider. Every nursing home should have a copy of the SOM. In addition, activities will be a huge help for you. When a person is participating in activities, that keeps them busy, but, of course, activities that that person would be interested in. That is where your investigative and creative skills come in with each resident. What interests him or her?

Also ask, WHY is the resident getting up? What does he or she want to do? What is the pattern? Is it all the time or at specific times? Does he or she need to use the bathroom, or perhaps the resident is hungry, or bored. Is the chair comfortable or is the resident so uncomfortable he or she has to get up (we all know how uncomfortable some chairs can be). What did the person do as a career? Is that why he or she is getting up. Is he or she looking for something specific to do? Maybe the resident worked the night shift and is used to staying up all night and sleeping in the afternoon. These are just a few of the questions you can consider to help you figure out how to keep the resident safe while at the same time keeping the resident as free from restraints as possible. Perhaps your resident just needs someone with him or her all the time to interact, provide companionship, and stimulating conversation (whether or not the resident can respond).

I would also suggest you network with other nursing homes (I’m assuming you are working in a nursing home) and gather ideas and information about what works for them, how their activities departments help and how they keep residents with dementia safe while allowing them to walk. A resident who walks is going to be maintaining stronger muscles and better walking ability than one who is forced to sit in a chair all day.

There is no pat answer to the regulations and how to stay in compliance. Each situation requires its own determination of what will work. That is one of the great challenges and opportunities that nursing home staff have. This is also one area that nursing home and hospital surveyors will continue to review and question.

JL

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In the previous article I listed for you the actual regulations that surveyors use regarding restraints in Hospitals and Nursing Homes. Lets look at what these regulations mean, i.e. – the guidance the Nursing Home and Hospital Surveyors use when doing a survey in a nursing home or hospital.

As you may realize as you read the regulations, the ones for the hospital cover the use of restraints in medical and post-surgical care and the emergency use of restraints in behavior management. The requirements are to be applied to a situation, not a treatment setting. In other words, you as a consumer who wants to learn about this, and surveyors who are surveying this issue should not look at the fact that the person is in a hospital. Instead you and/or the surveyor (and also the hospital staff) should look at the specific situation that is happening to determine if a patient really needs a restraint. Restraints aren’t the answers to every situation and, in fact, they can exacerbate issues instead of solve problems. Restraint use decisions are correctly done by doing a comprehensive physical & individual assessment.

This assessment should address at least the following questions: Are there safety interventions or precautions that can be taken to reduce the risk of the patient slipping, tripping, or falling if the patient gets out of bed? Is there a way to enable the patient to safely ambulate? Is there some assistive device that will improve his or her ability to self ambulate? Is a medication or a reversible condition causing this unsteady gait? Would the patient be content to walk with a staff person? Could the patient be brought closer to the nurse’s station where he or she could be supervised?

In order to properly use a restraint, the results of the assessment would need to conclude that for this patient at this time, the use of less intrusive measures poses a greater risk than the risk of using a restraint or seclusion. Doing this assessment would identify any medical problems that can cause behavioral changes in a patient. Restraints are not used for “diagnoses”. Instead, addressing medical issues can sometimes eliminate or minimize the need for the use of restraints.

If the assessment reveals there is a real medical symptom or condition that indicates a need for a restraint to protect the patient from harm, the regulation at 482.13(e)(3) requires that the hospital first determine that less restrictive interventions are ineffective. Only after making this determination, can the hospital consider the use of a restraint. However, that consideration should weigh the risks of using a restraint against the risks presented by the patient’s behavior. There is a great deal research that shows that restraints actually can increase risks rather than abate risks.

But, you say, the patient might fall and hurt him or herself – therefore he or she needs that restraint for his/her own safety. Or maybe you are thinking: But so and so gets up at night and wanders in the hall or walks to the bathroom. There is nothing inherently dangerous about a patient in a hospital being able to walk or wander, even at night. CMS and accepted restraint guidelines explain that for the purposes of the CMS regulations the rationale that the patient should be restrained because he/she “might” fall is an inadequate basis for using a restraint.

Instead, the hospital must ensure that when assessing and care planning for the patient the staff should consider whether the patient has a medical condition or symptom that truly indicates there is a current need for a protective intervention (i.e. a restraint) to prevent the patient from walking or getting out of bed. Even a history of falling is inadequate to demonstrate the need for restraint when there is no current clinical basis for a restraint. It is important to note that regulations specifically state that convenience is not an acceptable reason to restrain a patient. A restraint must not serve as a substitute for adequate staffing to monitor patients. A hospital surveyor will also look to see that restraints must never act as a barrier to the provision of safe and appropriate care, treatments, and other interventions to meet the needs of the hospital patient.

As we have been showing you, patients have the right to be free from a restraint or seclusion that is not medically necessary. Hospitals must ensure that this right is implemented. The hospital must take actions to comply with the requirements and must monitor its compliance through Quality Assurance and Performance Improvement activities. Hospital leadership should be assessing and monitoring the use of restraint/seclusion, and they should be implementing actions to ensure that only medically necessary restraints are used. When restraints are used the hospital must ensure it complies with the regulations/requirements and that the restraints are removed as soon as possible.

Be safe and be informed!

JL

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There are Federal regulations for both hospitals and nursing homes that cover the use of restraints in both types of facilities. Nursing Home Surveyors and Hospital Surveyors use these regulations as they conduct Hospital Surveys and Nursing Home Surveys. The regulations and their accompanying guidance cover many pages of the interpretive guidelines that we have discussed previously. First, I will list the Federal regulations regarding restraints in Hospitals and their regulation number:

  • 482.13(e)(1) The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff.
  • 482.13(e)(2) A restraint can only be used if needed to improve the patient’s well being and less restrictive interventions have been determined to be ineffective.
  • 482.13(e)(3) The use of a restraint must be–
  • (i) Selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm.
  • 482.13(e)(3)(ii) In accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital or order a restraint. This order must–
  • 482.13(e)(3)(ii)(A) Never be written as a standing or on an as needed basis (that is, PRN); and
  • 482.13(e)(3)(ii)(B) Be followed by consultation with the patient’s treating physician, as soon as possible, if the restraint is not ordered by the patient?s treating physician;
  • 482.13(e)(3)(iii) In accordance with a written modification to the patient’s plan of care;
  • 482.13(e)(3)(iv) Implemented in the least restrictive manner possible.
  • 482.13(e)(3)(v) In accordance with safe and appropriate restraining techniques, and
  • 482.13(e)(3)(vi) Ended at the earliest possible time.
  • 482.13(e)(4) The condition of the restrained patient must be continually assessed, monitored, and reevaluated.
  • 482.13(e)(5) All staff who have direct patient contact must have ongoing education and training in the proper and safe use of restraints.
  • 482.13(f)(1) The patient has the right to be free from seclusion and restraints, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.
  • 482.13(f)(2) Seclusion or restraint can only be used in emergency situations if needed to ensure the patient?s physical safety and less restrictive interventions have been determined to be ineffective.
  • 482.13(f)(3) The use of a restraint or seclusion must be–
    • (i) Selected only when less restrictive measures have been found to be ineffective to protect the patient or others from harm.
  • 482.13(f)(3)(ii) In accordance with the order of a physician or other licensed independent practitioner permitted by the State and hospital to order seclusion or restraint.
  • 482.13(f)(3)(ii)(A) Orders for the use of seclusion or a restraint must never be written as a standing order or on an as needed basis (that is, PRN).
  • 482.13(f)(3)(ii)(B) The treating physician must be consulted as soon as possible, if the restraint or seclusion is not ordered by the patient’s treating physician.
  • 482.13(f)(3)(ii)(C) A physician or other licensed independent practitioner must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention.
  • 482.13(f)(3)(ii)(D) Each written order for a physical restraint or seclusion is limited to 4 hours for adults; 2 hours for children and adolescents ages 9 to 17; or 1 hour for patients under 9. The original order may only be renewed in accordance with these limits for up to a total of 24 hours.
  • 482.13(f)(3)(iii) In accordance with a written modification to the patient’s plan of care;
  • 482.13(f)(3)(iv) Implemented in the least restrictive manner possible;
  • 482.13(f)(3)(v) In accordance with safe appropriate restraining techniques; and
  • 482.13(f)(3)(vi) Ended at the earliest possible time.
  • 482.13(f)(4) A restraint and seclusion may not be used simultaneously unless the patient is–
    • (i) Continually monitored face-to-face by an assigned staff member; or
  • 482.13(f)(4)(ii) Continually monitored by staff using both video and audio equipment. This monitoring must be in close proximity to the patient.
  • 482.13(f)(5) The condition of the patient who is in a restraint or in seclusion must continually be assessed, monitored, and reevaluated.
  • 482.13(f)(6) All staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application and techniques and alternative methods for handling behavior, symptoms and situations that traditionally have been treated through the use of restraints or seclusion.
  • 482.13(f)(7) The hospital must report to CMS any death that occurs while a patient is restrained or in seclusion, or where it is reasonable to assume that a patient’s death is a result of restraint or seclusion.

As opposed to the regulations in Hospitals, the regulations in Nursing Homes that a Hospital and Nursing Home Surveyor refers to are much shorter, yet just as important. Here is the regulation for Restraints in Nursing Homes:

  • 483.13 (a) Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.

Now it would seem that hospitals are much more regulated in terms of restraints, yet they actually have more latitude in many ways. In future posts we will spend some time discussing these regulations and what they really mean.

Be safe and be informed!

JL

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