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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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10 Responses to “Surveying Restraint Regulations in Hospitals or Nursing Homes – Part I”

  1. sue frances Says:

    In June, 2008 my husband fell out of bed at the hospital, after my son and I requested that all four of the railings be put up. This had set his recovery back 4 weeks. When he was transferred to the rehab center, my and myself requested that all four railings be put up so this would not happen again. From the previous fall and the medications my husband was on caused him to have hallucinations and bad dreams. My husband was afraid that he again would fall out of bed. They refuse to listen and have one railing tied down so that it cannot be put up. Instead of providing a safe environment for each patient on an individual basis everyone is lumped together. It seems the hospitals and nursing homes would welcome the information from the patients and their families on what safeguard should be in place. I would appreciate your comments.

  2. JL Says:

    Hi Sue,

    I defintely understand your frustration. The regulations are designed to ensure that nursing homes and hospitals keep patients safe in the way that is best for the patient. For the most part, siderails are dangerous because people get caught in them or crawl over them and get injured. If your husband is having hallucintations, they are possibly afraid he would try to crawl over the siderail and then injure himself more. Siderails have lead to deaths. There are kinds that are less dangerous than others.

    The facility has a responsibility to ensure your husband is safe and they must take his requests and needs into consideration. They must make every effort to keep him safe, and there are alternatives to siderails they could consider, that would help your husband feel safe. The regulations do not say that nursing homes and hospitals cannot ever use siderails. There are instances where the facilty can use them – but they must be sure they have careplans in place and knowledgable staff.

    My suggestion is for your husband to ask for a care planning meeting and that you attend and start taking notes.(It should be your husband who asks, if he is his own power of attorney and can make decisions for himself). They are required to have a meeting at times when he and you can attend and it should not be put off for very long. It shuold be abel to be arranged in a reasonable amount of time. At the meeting your husband needs to clearly express his desires to be safe, and that he thinks a siderail is the safeest for him, but also ask the facility if there is an alternative to a siderail, (for instance, a bed that is lower to the ground and a mat on the floor, so in case your husband does have a bad dream and he rolls out he he doesn’t have far to fall and that there is something soft to catch him and prevent injury). The facility should have a care plan in place addressing his fears and his desires for the siderail. Ask to see that care plan and see what it says. Ask them for other “less restrictive” ideas that would help him feel safe and be safe.

    Keep detailed notes as to what is happening and their responses. If something does happen because they aren’t taking appropriate safety measures, you then have a record of what had been occurring.

    I hope my answer is helpful to you in ensuring the care is safe for your husband. Be an advocate for him!

    JL

  3. Kathy Says:

    I have a resident to has dementia and we have a self-releasing, alarming belt on him. He has fallen three times and the last time caused a sacral fracture. This is what led to applying the belt. He is able to release it on his own if we show him how, but, to ask him to release it, he does not comprehend this due to his dementia. The state is now saying we need a diagnosis that gives a reason that he needs this. I understand that a resident has the right to fall. But, if his falling can be prevented, why is this wrong

  4. Kathy Says:

    and what diagnosis would be correct if dementia doesn’t give enough of a diagnosis to use ? What lesser measures that we tried were a chair alarm which did not work as she is too fast ,bed alarm which did not work for the same reason and keeping her at our sides as much as posible. Please resond.

  5. Answering Kathy’s Question about Surveying Restraints in a Nursing Home or Hospital | Nursing Home & Hospital Surveyor Says:

    […] 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“. […]

  6. Sandra A. Bradley Says:

    When a patient is placed in a low bed with a mat beside the bed, the patient rolls out of the bed onto the mat, I would still document this action as a fall? Thank you.

  7. admin Says:

    Hi Sandra,
    Yes, this would constitute a fall. The interpretive guidelines state the following about falls:
    “Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.1

  8. Teresa Says:

    my husband tried to commit suicide by taking a
    large dose of xanax while at the hospital he became violent they put him in leahther straps arms&legs he was in these the entire length of his stay which was from 10pm sat until 5pm monday.
    was this legal?I can understand them leaving in them until he was completely out from under the
    drugs but when he actually came out he was fine
    and treating everyone with respect so why was he not aloud of the restraints.

  9. admin Says:

    Many times the hospital staff are afraid for their safety even when someone seems quieter. The physician orders restraints upon his/her assessment of the individual or upon the assessment of a nurse who then asks for the order. The staff could have asked for the order to be removed or to “try” him without restraints and if he got violent again, put them back on. Without knowing the reasoning for the staff to keep them on, it’s only a guess as to why they did not remove them after he calmed down. Restraints are to be used to treat MEDICAL SYMPTOMS, and violence could interfere with treatment, so they could use them, but once he was not violent they have a responsibility to reassess the need for restraints.

  10. Nursing Home Administrators Says:

    Actually, a nursing home resident doesn’t actually have the “right to fall”. This is not one of the federally guaranteed rights for nursing home residents. They do, however, have the right to make decisions for themselves and refuse medical treatments (or restraints). They also have the right to be free from restraints as JL has outlined above. This, of course, sometimes leads to falls. We typically are expected to create alternative interventions and take a look at our care plan goals to see if they’re realistic. Maybe the goal shouldn’t be “will have no falls…” Maybe it should be “will suffer no injury from falls…”

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