Best Practices in Hospital Restraint and Seclusion: 2023 CMS Updates

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RESTRAINT AND SECLUSION 2023

Navigating a Problematic CMS Standard

2 Speaker ▪ Laura A. Dixon, Esq. ▪ BS, JD, RN, CPHRM ▪ President, Healthcare Risk Education and Consulting, LLC ▪ 303-955-8104 ▪ ldesq@comcast.net ▪ Email questions to CMS: Critical Access Hospitals: qsog_CAH@cms.hhs.gov. Acute hospitals: qsog_hospital@cms.hhs.gov. 2

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, 1996:;275(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 R&S, OIG and HHS, at http://oig.hhs.gov/oei/reports/oei

09 04 00350.pdf 3

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 patient’s 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/PMC8859 077/pdf/NOP2-9-1311.pdf

Introduction to the CoPs on Restraint and Seclusion

2019 Changes to R&S*

▪ Changed “licensed independent practitioner” to “licensed practitioner”

▪ Allows Physician Assistant to order R&S 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

Number of R&S 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 9
R&S 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 R&S 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 10
Deficiencies Tag Number January 2023 180 State Can Be More Restrictive 3 182 RN Consultation with Attending 15 183 Continuous Monitoring for R&S 4 184 Documentation: 1-hour F2F 39 185 Documentation: Behavior and Intervention Used 54 186 Documentation: Alternatives Used 47 187 Documentation: Patient’s Condition 37 188 Documentation: Patient’s Response 52 194 Staff Training Required 71 196/199 Training Intervals & Content 93/19 11
R&S
12 Tag Number January 2023 200 Training: Non-physical Intervention 36 201 Training: Least Restrictive Methods 8 202 Training: Safe Application R&S 35 204 Training: Identify R&S Can Be D/Cd 3 205 Training: Patient Monitoring R&S 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
R&S Deficiencies

CMS Surveyor Training Website

Complaint Manual

CMS Hospital CoPs on Restraint and Seclusion

SECLUSION

RESTRAINTS

Standards and Guidelines

Not Covered By Rule – Law Enforcement

▪ What:

▪ Handcuffs

▪ Who:

▪ Non-hospital

▪ Manacles

▪ Shackles

▪ Other chain-type restraint devices

▪ Not hospital staff:

▪ Not considered safe nor appropriate interventions

▪ Ensure P&P mention

▪ 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 selfdestructive person

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Items to Document

▪ Skin integrity

▪ Circulation

▪ Respiration

▪ I&O

▪ Level of supervision appropriate to meet patient’s safety need

▪ Hygiene

▪ Any injuries

▪ Continued need for use

▪ Adequate justification for continued use

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JOINT COMMISSION RESTRAINTS AND SECLUSION

22 The End Questions??? ▪ Laura A. Dixon, Esq. ▪ BS, JD, RN, CPHRM ▪ President, Healthcare Risk Education and Consulting, LLC ▪ 303-955-8104 ▪ ldesq@comcast.net Register Now

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