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Complying with the CMS Restraint and Seclusion Standards: the Most Problematic CMS Standard

CMS has about 50 pages that address the restraint and seclusion standards, the most problematic standard in the hospital CoP manual. Here’s the evidence: the Jan. 15 CMS quarterly deficiency reports shows 1,289 deficiencies from tag 154 to 214.

All patients have to right to be free from unnecessary restraint and seclusion. A restraint is defined to include any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. Mechanical restraints include wrist restraints, vest restraints, elbow immobilizers, ties, or cuffs. However, most hospitals report no longer using vest restraints. Tucking patients’ sheets so tightly they cannot move or wrapping patients up in a sheet would constitute a restraint. The use of an enclosure bed that prevents the bed from freely exiting would also constitute a restraint. A patient who is unable to freely exit a geri chair or a wheelchair with a seat belt on could also be construed by the CMS surveyor to be a restraint. Hospitals should include the definition of what constitutes a policy in the hospital’s policy and procedure.

The policy should also include what constitutes a drug used as a restraint. This could include a drug used as a restriction to manage the patient’s behavior and is not part of a standard treatment or standard dosage for the patient’s condition. This could include using an off label drug or a dose that is two or three times the normal dosage. A drug is not a restraint if the medication is within the pharmacy parameter set by the FDA and the manufacturer for use. If it follows a national practice standard, is used to treat a specific condition based on the patient’s symptoms, or is standard treatment to enable the patient to be more effective, then it is not a drug used as a restraint. An example would be the use of Ativan for a patient with alcohol withdrawal symptoms.

CMS’s terminology is different than that of The Joint Commission (TJC). TJC is one of the four accreditation organizations (AOs) that have deemed status. This means that hospitals that are accredited by one of the four AOs can get paid for taking care of Medicare patients without have CMS do a survey every three years or so. CMS uses the terminology that the patient is either violent and or self destructive or non-violent and non-self destructive. TJC refers to the patients as either behavioral health or non-behavioral health patients. CMS says it is not the department that the patient is located but the behavior.

Part two will include recommendations to ensure compliance with the restraint and seclusion standards. CMS requires on-going education so hospitals should consider annual training for all staffs who work with patients in restraint or seclusion. CMS has ten pages of educational requirements and the hospital should ensure staff on trained on everything on the list. The policy should include any state specific laws or accreditation organization requirements. Many states have specific laws for hospitals that have a separate behavioral health department. Staff should be trained in the policy. CMS requires that any physician or other licensed independent practitioner who writes an order for restraint and/or seclusion should be trained on the hospital policy. This is why some hospitals will provide a copy of the current policy and have these practitioners sign an attestation that is put in their file during the every two year re-credentialing and re-privileging process that they have received a copy of the current policy and have read and understand it. This process should also be done whenever there is a significant change in the hospital policy and procedure.

  • The deficiency reports are here.
  • The current CMS CoP manual is here.