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.


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I am in the midst of explaining some concepts to you about how a nursing home surveyor prepares to conduct a nursing home survey. This is Part 3. I talked a little about the two forms of Survey, the QIS survey and the Standard survey. I want to explain, now, the Tasks for the QIS nursing home survey that the nursing home surveyors must do.

The QIS Tasks are:

  • Task 1: Offsite Survey Preparation. This includes an initial resident sample selection. During this task the nursing home surveyors also review files, previous complaints and surveys, and other information in order to be familiar with the issues the nursing home survey team might encounter while at the nursing home.
  • Task 2: Onsite Preparatory Activities and Entrance Conference. This is where the nursing home survey team lets the facility know what to expect during the survey. The team gathers additional paperwork and nursing facility information and continues to develop the plan for the survey.
  • Task 3: The Initial Tour. Upon entering a nursing facility the nursing home surveyors do a tour of the facility prior to commencing with the investigative portion of the survey. This is different than a Hospital survey in that hospital surveys do not have an initial tour.
  • Task 4: Stage I Survey Tasks. These include finalizing the sample selection, conducting nursing home survey team meetings, gathering information, reviewing records, and interviewing staff, residents, and families.
  • Task 5: Non-Staged Survey Tasks. This includes more interviews, reviews of policies and procedures, Abuse Prohibition review, Quality Assessment and Assurance review, observation of the food services, and reviews of billing.
  • Task 6: Transition From Stage I to Stage II. During this stage of the QIS process the nursing home survey team updates the resident sample, reviews what was found in Stage I, puts data into the laptop and reviews the analysis of the findings (the QCI’s mentioned previously)
  • Task 7: Stage II Survey Tasks. This is again composed of more sampled resident reviews, team meetings, more investigation, observation of the Medication administration, Environmental observations, reviews of resident funds, reviews of admission, transfer and discharge issues, and facility staffing.
  • Task 8: Analysis and Decision-Making. This is where all the information is integrated and analyzed in order to determine what areas are non compliant.
  • Task 9: Exit Conference. This is where the nursing home surveyor and the team provide information about their preliminary findings to the nursing home.

In the next post we will continue with the process a Nursing Home and Hospital Surveyor follows when conducting a nursing home survey.

Keep informed and keep safe!


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As mentioned in the other posts talking of this issue, CMS has guidance in the SOM for nursing home surveyors to follow. The third piece of the investigation is the review of the resident’s record and other facility documents. The nursing home surveyor will review the resident’s assessment, the history and physical and other portions of the clinical record. These items should include the information needed to determine the resident’s needs and the interventions needed to meet the resident’s needs. The surveyor should be looking for consistency among the various parts of the record as well as with the observations that have been made and the interviews that were conducted.

The plan of care should be reviewed to see if it contains the detail needed to meet the resident’s needs. Each care plan should be individualized to each resident, so the surveyor is going to be looking to see that the care plan is not the same for most residents in the facility. An example of this would be “Toilet the resident before and after meals and at bedtime”. When I see this as a surveyor it starts ringing bells. Again, as mentioned before in this series of posts, everyone has their own pattern of needing to use the bathroom. Residents don’t fit into a cookie cutter. The plan should be based upon the goals, needs, and strengths specific to the resident and it should reflect the comprehensive assessment. It should identify objectives, timeframes, potential complications, and even environmental obstacles that affect the resident. Every care plan, whether for this issue or another, should identify specific approaches and interventions and should include input by the resident and/or the responsible person.

The information I have provided in the posts on this topic are just the “tip of the iceburg”. You will find much more information in the SOM and I encourage you to take some time to read and review it, especially if you are in a nursing home or have a loved one in a nursing home.

Be safe and informed!


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