Restraint and Seclusion Navigating a Problematic CMS Standard

Restraint and Seclusion is a hot spot with both CMS and the Joint Commission and a common area where hospitals are cited for being out of compliance. The restraint policy is one of the hardest to write and understand in healthcare today.

CMS made significant changes in restraints in 2019. Specifically, CMS changed the term from LIP - licensed independent practitioner to LP (licensed practitioner). The change allows PAs to write orders for restraints in states where they are considered dependent practitioners. The changes will be discussed in detail.

The number one area of deficiencies for a specific requirement in the CMS CoP is regarding restraints. CMS permits access to the deficiencies against hospitals which is updated quarterly. This program will discuss the most problematic standards in the restraint section.  

Did you know any physician or provider who orders restraint must be trained in the hospital’s policy? Did you know that both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis? This program can be used to help hospitals meet this requirement. CMS also says that restraint training must be ongoing so you cannot just provide training at orientation and forget about it. CMS has ten pages of training requirements.

This program will discuss the requirements for an internal log and what must be in the log for patients who die in one or two soft wrist restraints. It will include what must be documented in the medical record also. It will also discuss the new electronic reporting requirements for patients who die in restraints and within 24 hours of being in a restraint.

• Introduction to CoP Manual
• CMS deficiencies and access 
• Complaint manual
• CMS changes to restraint and seclusion
  • PA may write orders
  • Internal log and soft wrist restraints
• Conditions of Participation for CAH
• Learning from Each other
• Seclusion – what it is and is not
• Medical restraints
• Behavioral health restraints 
• Violent and self-destructive behavior
• Definition of restraint and seclusion
• Manual holds of patients, 
• Leadership responsibilities
• Two soft wrist restraints, internal log, and documentation
• Culture of Safety
• Drugs used as a restraint 
• Standard treatment
• Restraints do not include
• Side rails, forensic restraints, freedom splints, immobilizers
• Assessment
• Need order ASAP
• Order from LIP and notification of attending physician ASAP
• Documentation requirements 
• Least restrictive requirements
• Alternatives 
• RNs and One-hour face-to-face assessment
• Training for RN doing a one-hour face-to-face assessment
• New training requirements
• New death reporting requirements
• Ending at the earliest time
• Revisions to the plan of care
• Time-limited orders 
• Renewing orders 
• Staff education
• First aid training required
• Monitoring of patients in R/S
• Joint Commission Hospital Restraint standards and differences from CMS

• 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
• Senior leadership
• Hospital legal counsel
• Chief Risk Officer
• PI director
• Joint Commission coordinator
• Nurse managers
• Quality director
• Chief medical officer
• Security guards
• Compliance officer 
• Accreditation and regulation staff and others responsible for compliance with hospital regulations
• Anyone involved in the restraint or seclusion of patients.
• Persons are responsible for rewriting the hospital policies and medical staff bylaws.
• Staff that removes and applies them as part of their care such as radiology techs, ultrasound technologists, transport staff, and others.