CMS Hospital Restraint and Seclusion: Best Practices

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RESTRAINT AND SECLUSION2023Navigating a
Problematic CMS Standard
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Speaker

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net
• Email questions to CMS
  Critical Access Hospitals
  qsog_CAH_at_cms.hhs.gov. Acute
  hospitals qsog_hospital_at_cms.hhs.gov.

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Rethinking Restraints in Hospitals

• Study found 27,000 patients restrained every
• About 5 per hospital and prevalence is 50 per
  1,000 patient days
• 2007 Study in Journal of Nursing Scholarship, Vol
  39, Issue 1, Page 30-37, Prevalence and Variation
  of Physical Restraint Use in Acute Care Settings
  in the US
• Restraints increase the risk for delirium by
  4-fold
• JAMA March 20, 1996275(11)852-857,
  Precipitating Factors for Delirium in
  Hospitalized Elderly Patients
• Restraints increase the rates of pressure ulcers,
  respiratory complications and even death via
  strangulation and aspiration
• HHS study in 2006 found that 40 of hospitals
  fail to report deaths to CMS
• Hospital Reporting of Deaths Related to RS, OIG
  and HHS, at http//oig.hhs.gov/oei/reports/oei-09-
  04-00350.pdf

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Why RNs Reduce Need for Restraints

• If low number of registered nurses
• Odds of using restraints were 11 and 18 higher
• Use of restraints to prevent a fall were 9 to 16
  higher
• RNs are better trained to find alternatives to
  restraint and seclusion
• Physical restraints can include belts, mittens,
  vests (note most hospitals do not use), bedrails,
  geriatric chairs, and other devices
• It is not the number of staff present to reduce
  falls but rather having adequate number of RNs

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2022 Article Use of Restraints in Hospitals

• Study utilized three topic-based focus groups
• 19 participants from nursing, PT and medicine
• Participants noted lack of precise hospital
  guidelines
• Documentation often lacked the effect of
  restraint on patients behavior
• Restraints were described as a safety measure
• Implementation most often led by nurses
• Attitudes and experiences were main detriments
  for restraint use
• Experienced nurses tended to use restraints less
• Prior experience with violence ? more use
• https//www.ncbi.nlm.nih.gov/pmc/articles/PMC88590
  77/pdf/NOP2-9-1311.pdf

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Introduction to the CoPs on Restraint and
Seclusion
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2019 Changes to RS

• Changed licensed independent practitioner to
  licensed practitioner
• Allows Physician Assistant to order RS in state
  that held the PA was a dependent practitioner
• Physician and other licensed practitioner
  training requirements must be specified in the
  hospital policy

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Hospital Deficiency Data
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Number of RS Deficiencies
Tag Number January 2023
154 Use of Restraint or Seclusion 273
159 Definition physical restraint 38
160 Definition chemical restraint 78
161 What Is/Is Not a restraint 18
162 Definition seclusion 39
164 Less Restrictive Ineffective 118
165 Type Least restrictive 89
166 Written Modification of Plan 237
167 Safe Appropriate Technique 197
168 Order Required 677
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RS Deficiencies
Tag Number January 2023
169 Never a Standing Order 91
170 Attending Consultation 27
171 Time Limits for Restraints 140
172 Assessment in 24 Hours 16
173 Order Renewed by Policy 77
174 D/C RS Earliest Possible Time 170
175 Trained Staff Monitor Patient 318
176 Training Requirements in Policy 53
178 One-Hour Face-to-Face 172
179 One Hour Evaluation Elements 163
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RS Deficiencies
Tag Number January 2023
180 State Can Be More Restrictive 3
182 RN Consultation with Attending 15
183 Continuous Monitoring for RS 4
184 Documentation 1-hour F2F 39
185 Documentation Behavior and Intervention Used 54
186 Documentation Alternatives Used 47
187 Documentation Patients Condition 37
188 Documentation Patients Response 52
194 Staff Training Required 71
196/199 Training Intervals Content 93/19
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RS Deficiencies
Tag Number January 2023
200 Training Non-physical Intervention 36
201 Training Least Restrictive Methods 8
202 Training Safe Application RS 35
204 Training Identify RS Can Be D/Cd 3
205 Training Patient Monitoring RS 22
206 Training First Aid and CPR 94
207 Training By Qualified Trainers 6
208 Documentation of Training 56
213 Death Reporting to CMS 25
214 Death Reporting Internal Log 46 Total 3,759
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CMS Surveyor Training Website
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Complaint Manual
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CMS Hospital CoPs on Restraint and Seclusion
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SECLUSION
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RESTRAINTSStandards and Guidelines
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Not Covered By Rule Law Enforcement

• What
• Handcuffs
• Manacles
• Shackles
• Other chain-type restraint devices
• Not hospital staff
• Not considered safe nor appropriate interventions
• Ensure PP mention

• Who
• Non-hospital
• Employed
• Contracted law enforcement
• Purpose
• Custody
• Detention
• Public Safety

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Restraint Chair Used by Law Enforcement

• Emergency restraint chair
• Manufacturer states used for safe transports to
  hospital or court
• Safely restrains a combative or self-destructive
  person

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Items to Document

• Skin integrity
• Circulation
• Respiration
• IO
• Level of supervision appropriate to meet
  patients safety need

• Hygiene
• Any injuries
• Continued need for use
• Adequate justification for continued use

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JOINT COMMISSION RESTRAINTS AND SECLUSION
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The End Questions???

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net

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