CMS Hospital Restraint and Seclusion - Guidelines 2024

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RESTRAINT AND SECLUSION 2024 A Problematic CMS
Standard
Presented By Laura A. Dixon, Esq. BS, JD, RN,
CPHRM President, Healthcare Risk Education,
and Consulting, LLC 1
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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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CMS Investigates Restraint Death

• March 2017 article Greenville Hospital to lose
  its Medicare contract unless it corrects a
  deficiency in a CMS Survey
• 48-year-old patient dies while strapped to a
  gurney
• Died of traumatic asphyxiation
• Coroner said his death was a homicide
• Admitted with gun shot wound to his arm
• He struggled with hospital security who secured
  him face down on a gurney

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More RNs Reduce Need for Restraints

• August 2016 study found restraints are used less
  when
• more nurses are on duty
• Use of restraints has declined steadily
• Restraints can lead to agitation, confusion, and
• adverse psychological and health effects
• Some hospitals compensate the shortage of RNs
  with other staff
• Found this leads to increase in restraint use and
  that quality
• of care suffers
• Staggs, V.S., Olds, D.M., Cramer, E. et al. J GEN
  INTERN MED (2016). doi10.1007/s11606-016-3830-z
  at http//link.springer.com/article/10.10072Fs11
  606-016-3830-z

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2022 Article 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/NO P2-9-1311.pdf

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INTRODUCTION TO CONDITIONS OF PARTICIPATION
Restraint and Seclusion
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How it Works

• Regulation published in the Federal Register
• CMS publishes the regulation in a transmittal
• Will develop Interpretive guidelines and survey
  procedures
• Updates the hospital CoP manual
• Types of surveys
• Certification
• Complaint
• Validation survey

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CMS COMPLAINT MANUAL
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Death Reporting Investigations 5170

• Applies to all deemed, non-deemed hospitals, CAH
  distinct part psychiatric (DPU) and rehab units
• Required to report death associated with use of
  restraint/seclusion to Regional Office NOT
  State agency
• Submit report electronically by fax/email Form
• 10455
• ASPEN Automated Survey Processing Environment
• ACTS Complaint Tracking System

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Conditions of Participation Restraint Seclusion
Tag Nos. 154 214
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SELUSION Tab No. 162
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Definition 162

• Seclusion
• Involuntary confinement
• Alone in a room or area
• From which they are physically prevented from
  leaving
• May only be used for the management of violent or
• self-destructive behavior (V/SD behavior)
• Jeopardizes the immediate physical safety of the
  patient, a
• staff member, or others
• (Only tag number where seclusion identified
  separately)

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Reducing Use of Seclusion

• Learning from Each Others Success Stories and
  Ideas for Reducing Restraint/Seclusion in
  Behavioral Health
• Tools and forms in appendix
• Tool for behavioral health patients
• Published in 2003 by many organizations
  including
• American Psychiatric Nurses Assn. National
  Association of Psychiatric Health Systems
  (NAPHS) with support of AHA
• See NAPHS and AHA guiding principles1
• 1 www.naphs.org www.apna.org, www.psych.org, or
  www.apna.org,
• http//www.naphs.org/catalog/ClinicResources/index
  .html

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RESTRAINTS Standards and Guidelines
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Restraint and Seclusion 154

• All patients have a right to be free from
  unnecessary physical or mental abuse, and
  corporal punishment
• Only used
• When necessary
• Not as coercion, discipline, convenience or
  retaliation
• For patient safety
• Discontinued at earliest possible time

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Reasons to Restrain

• Check all that apply
• Unable to follow directions for safety
• Aggressive
• Disruptive/combative
• Self injury
• Interference with treatments
• Removal of medical devices
• Other

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Medical Condition Need for Restraint

• If the assessment indicates a need to protect the
  patient from harm must use least restrictive
  intervention
• Can consider restraint
• Weigh risk of using restraint against risk
  presented by
• behavior
• Request by patient/family not sufficient basis
• If need confirmed practitioner must determine
  type with least risk and most benefit

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Documentation

• Staff must demonstrate restraint is least
  restrictive
• Through documentation
• Protects patient
• Based on assessments
• Assessments and documentation must be ongoing to
• show continued need
• Once a day may not be sufficient clinical
  condition changes over time

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Use of Weapons

• Use of weapons in application of restraint or
  seclusion not considered a safe, appropriate
  health care intervention
• Pepper spray Mace Nightstick Tasers
  Cattle prods
• Stun guns Pistols
• Security can carry per policy, State/Federal law
• Not considered health care intervention
• Is a law enforcement action
• CMS does not support use of weapons by any
  hospital staff as a means of subduing a patient
  to place in restraint/seclusion

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Not Covered By Rule Law Enforcement

• What

• Who

• Handcuffs
• Manacles
• Shackles
• Other chain-type
• restraint devices

• Non-hospital
• Employed
• Contracted law
• enforcement

• Purpose

• Not hospital staff

• Custody
• Detention
• Public Safety

• Not considered safe nor appropriate
  interventions
• Ensure PP mention

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Items to Document

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

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

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JOINT COMMISSION RESTRAINT AND SECLUSION
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Impact of Restraint

• TJC 40 of restraint-related deaths were caused
  by unintended asphyxiation during restraint
• Creates a negative response to the situation and
  can be
• humiliating to the patient
• Can be physically and emotionally traumatizing to
  the staff involved
• It impacts the trust between the patient and the
  staff
• Restraint and seclusion should be a last resort
• And only done to protect the patient or the staff

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Boarding Behavioral Health Patients

• Many hospitals board behavioral health patients
• pending an inpatient psyche bed due to a
  shortages
• Important to ensure that the patient is in a safe
  room to prevent inpatient suicide
• Many EDs have separate area to house these
  patients
• Free guide on how to create a safe room called
  the Behavioral Health Design Guide, at Facility
  Guideline Institute
• Includes self assessment tool

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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

Register Now
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