CMS Hospital Restraint and Seclusion: Navigating Most Problematic CMS Standards

Restraint and Seclusion is a hot spot with both CMS and the Joint Commission and an area where hospitals are frequently cited as non-compliance. This program will discuss this most problematic standard.

CMS has fifty pages of interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients will have to comply with the regulations even if accredited by the Joint Commission, HFAP, CIHQ, or DNV Healthcare.

Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis. CMS also says that restraint training must occur before a staff member/provider can apply or remove restraints and must be ongoing so it cannot occur at orientation only. There are ten pages of training requirements.

Finally, this program will briefly cover The Joint Commission standards on restraint and seclusion, many of which fall closely with the CMS Conditions of Participation.

• Recall that CMS requires all physicians and others who order restraints to be educated on the hospital policy.
• Describe that CMS has restraint education requirements for staff.
• Discuss that CMS has specific things that need to be documented in the medical record for the one-hour face-to-face evaluation of patients who are violent and or self-destructive.
• Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with two soft wrist restraints on.

• Restraints in the news.
• Introduction to CoP Manual.
• Deficiencies – restraints and seclusion.
• Complaint manual and process.
• Conditions of Participation.
• Seclusion – what it is and is not.
• Medical restraints.
• Behavioral health restraints.
• Definition of restraint and seclusion.
• Reasons to restrain.
• Leadership responsibilities.
• Falls and use of restraints.
• Drugs used as a restraint.
• What restraints do not include?
• Side rails, forensic restraints, freedom splints, immobilizers.
• Patient assessment.
• Need order ASAP.
• Order from LP and notification to attending physician.
• Documentation requirements.
• Least restrictive requirements.
• RNs and One-hour face-to-face assessment.
• Training for RNs doing the one-hour face-to-face assessment.
• Training requirements.
• Ending at the earliest time.
• Revisions to the plan of care.
• Time-limited orders.
• Renewing orders.
• Provider training.
• Staff education.
• First aid training is required.
• Monitoring of patient in R/S.
• Death reporting requirements.
• Joint Commission standards.

• All nurses with direct patient care.
• Compliance officer.
• Chief nursing officer.
• Chief of medical staff.
• COO.
• Nurse Educator.
• ED nurses.
• ED physicians.
• Medical staff coordinator.
• Risk manager.
• Patient safety officer.
• Chief Risk Officer.
• PI director.
• Joint Commission coordinator.
• Nurse managers.
• Quality director.
• Chief medical officer.
• Security guards.
• Accreditation and regulation staff and others responsible for compliance with hospital regulations.
• Anyone involved in the restraint or seclusion of patients.
• Any staff that could remove/apply restraints as part of care.