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CMS Restraint and Seclusion; the Most Problematic of All of the CMS Standards

Hospitals must ensure staff understands the definition of what constitutes restraint or seclusion. Remember, it’s not the thing that constitutes a restraint, but its effect on the patient.

If the nurse puts up all four side rails and the patient is not able to lower them, then this constitutes a restraint. If a physician or practitioner orders that all four side rails be up, the nurse should clearly document if the patient is able to lower them without assistance and exit the bed. The same is true of a geri chair. If the patient can exit the chair when they want, then this would not be a restraint.

Make sure the policy includes and staff is aware of what is not a restraint. Forensic restraints such as handcuffs, shackles or other restrictive devices applied by the police or other law enforcement are not restraints and this should be stated in the hospital policy. Orthopedically prescribed devices are not a restraint and could include a cast, double Shantz dressing, surgically dressing or protective helmet. Physically holding down a child or patient for routine physical exams or tests for medical reasons is not a restraint. An example would be holding a child while doing a lumbar puncture or using a papoose board while suturing.

However, a therapeutic hold on a child who is throwing things and acting out or a behavioral health patient would be a restraint. There is an exception for the narrow carts used in places like the emergency department or post anesthesia care unit (PACU). These carts are narrow and usually have one solid side rail and it is necessary to sometimes put these up for patient safety to prevent the patient from falling out of the cart.

Postural supports are also not a restraint. The patient is having knee surgery in the operating room so the knee is extended or the patient is in radiology having a knee MRI. An IV that is not tied or attached is also not a restraint. If a patient comes to the PACU still intubated this is not a restraint and is considered a continuation of the surgery.

The following recommendations will help prevent hospitals from receiving a deficiency in the area of restraint and seclusion:

  • Document the reason for the restraint. The state law determines who is an independent licensed practitioner (LIP). CMS allows physicians and other LIPs to order restraint and or seclusion. Restraints are generally ordered if the patient is a danger to themselves or others. This includes the need to prevent the patient from removing vital equipment or the lack of understanding of safety directions.
  • Alternatives to the use of restraints should be considered. One hospital uses low beds and has padded mats on the floor instead of restraining the patient. Another hospital uses a sitter. One hospital found that by using a plastic dome over the IV and using an elastic sleeve they did not need to use soft wrist restraints on the patients who were pulling out their IVs.
  • It is important to document the order in the chart. Restraints can be ordered by the physician or LIP, which includes licensed residents. The state determines who is a LIP, such as a nurse practitioner. If an order for two soft wrist restraints is written and later the patient needs ankle restraints, another order must be received. If the order is received by an LIP, then make sure the attending physician is notified as soon as possible. This should be documented in the medical record.
  • There are no PRN orders but the three exceptions recognized by CMS. This includes a patient with a repetitive self-mutilating behavior such as Lesch-Nyhan syndrome. A physician could enter an order that when patients are out of bed they be placed in a Geri chair. If the patient can’t get out of the Geri chair, then it would be a restraint. If the doctor writes to put up all four side rails and then if the patient cannot lower them, it would be a restraint.
  • There should be a plan of care for all admitted patients. If restraints are used, then the plan of care should be amended to include this.
  • The restraint should be removed at the earliest time. A trial release is seen as a PRN order and is not permitted. A temporary release is allowed such as releasing the restraint while feeding the patient, doing range of motion, or toileting the patient.
  • The patient should be reassessed according to the hospital’s policy and procedure. CMS does not specify any time frames such as every 15 minutes for patients who are violent or self destructive or every two hours for non-violent patients.
  • Hospitals should document the care given to patients in restraints and or seclusion. This may include fluids offered, toileting, positioning, vital signs, skin integrity assessment, patient behavior, and interventions used.
  • Restraints should be used as directed. The manufacturer’s directions should be followed. Hospitals should follow any state law or standards of care.
  • Patients who are violent should have a one hour face-to-face exam. These should be done by staff that is competent. Hospitals may want to consider having a form to collect the information required by CMS. This includes the patients’ reaction to the intervention, their medical and behavioral health history, need to continue, review of systems, history, and use of drugs or current medications. Time limited orders should be followed. Orders for an adult patient must be renewed every four hours. The practitioner needs to rewrite the order every 24 hours, not every calendar day, when a face-to-face assessment is done.

The hospital needs a policy and procedure and all the above information should be contained in the policy. The surveyor may look at the use of restraint and or seclusion to make sure it is consistent with the policy. The policy should be reflective of the CMS restraint standards and any specific state law requirements.

There is a long list of things that must be in the staff education. The policy should include what categories of staff are responsible for assessing and monitoring the patient. Staff members who are able to remove or apply restraints should be educated on their role. Staff in radiology or ultrasound technicians may need to move the patient onto a cart or table and then reapply them.

Hospitals should be aware of when a report is required to be made to CMS. If the patient dies in either one or two soft wrist restraints, that does not cause the death; the hospital must document this on an internal log and note in the chart that the internal restraint log has been completed. The internal log must include the patient’s name, date of birth, date of death, attending practitioner, medical record number and diagnosis.

Otherwise, if the patient dies in restraints within 24 hours of being in a restraint or if the restraint causes the death within seven days it must be reported on a form and submitted to CMS regional office. It should be reported no later than the close of business the next day. The form is available here on the CMS website.

A copy of the restraint standards can be located here on the CMS website under Appendix A. The manual was updated April 1, 2015.