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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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One Response to “Surveying Restraint Regulations in Hospitals or Nursing Homes – Part 2”

  1. Sharron Says:

    I’ll create a hyperlink to the web page about my personal weblog. I think this information letting the public know about nursing home surveyors and how nursing home and hospital surveys are done and how important they are is very interesting. Thanks for publishing Nursing Home and Hospital Surveyors!.

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