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Navigating Most Problematic CMS Standards - Hospital Restraint and Seclusion
The document discusses the issues surrounding the use of restraint and seclusion in healthcare settings, highlighting the necessity for careful guidelines and documentation to ensure patient safety and minimize adverse effects. It emphasizes that restraints should only be used as a last resort and in a manner that is least restrictive, while also addressing the negative consequences of restraint on both patients and healthcare staff. Additionally, it encourages hospitals to improve staffing levels and implement best practices to reduce the reliance on restraints.
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Navigating Most Problematic CMS Standards - Hospital Restraint and Seclusion
- 1. RESTRAINTAND SECLUSION 2024 AProblematicCMSStandard Presented By Laura A. Dixon, Esq. BS,JD, RN,CPHRM President, Healthcare Risk Education, and Consulting, LLC 1
- 2. 2 2 Speaker • LauraA. Dixon,Esq. • BS, JD, RN,CPHRM • President, Healthcare Risk Education andConsulting, LLC • 303-955-8104 • ldesq@comcast.net • Email questions toCMS: CriticalAccess Hospitals: qsog_CAH@cms.hhs.gov. Acute hospitals: qsog_hospital@cms.hhs.gov.
- 3. CMS Investigates RestraintDeath 3 • March 2017 article: Greenville Hospital to lose its Medicare contract unless it corrects a deficiency in a CMSSurvey • 48-year-old patient dies while strapped to a gurney • Died of traumatic asphyxiation • Coroner said his death was a homicide • Admitted with gun shot wound to his arm • He struggled with hospital security who secured him face down on a gurney
- 4. More RNs ReduceNeed for Restraints 4 • August 2016 study found restraints are used less when more nurses are on duty • Use of restraints has declined steadily • Restraints can lead to agitation, confusion, and adverse psychological and health effects • Some hospitals compensate the shortage of RNs with other staff • Found this leads to increase in restraint use and that quality of care suffers • Staggs,V.S.,Olds, D.M.,Cramer, E. et al. JGEN INTERN MED (2016). doi:10.1007/s11606-016-3830-z at http://link.springer.com/article/10.1007%2Fs11606-016-3830-z
- 5. 2022 Article: Restraintsin Hospitals • Study utilized three topic-based focus groups • 19 participants from nursing, PT and medicine • Participantsnoted 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/PMC8859077/pdf/NO P2-9-1311.pdf 21
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- 7. How itWorks • Regulationpublished in the Federal Register • CMS publishes the regulation in a transmittal • Will develop Interpretive guidelines and survey procedures • Updates the hospitalCoP manual • Types of surveys • Certification • Complaint • Validation survey 7
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- 9. Death Reporting &Investigations 5170 9 • Applies to all deemed, non-deemed hospitals, CAH distinct part psychiatric (DPU) and rehab units • Required to report death associated with use of restraint/seclusion to Regional Office – NOT State agency • Submit report electronically by fax/email – Form 10455 • ASPEN –Automated Survey Processing Environment • ACTS –ComplaintTracking System
- 10. Conditions of Participation Restraint&Seclusion Tag Nos. 154 – 214 10
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- 12. Definition 162* 12 • Seclusion: •Involuntary confinement • Alone in a room or area • From which they are physically prevented from leaving • May only be used for the management of violent or self-destructive behavior (V/SD behavior) • Jeopardizes the immediate physical safety of the patient, a staff member, or others (*Only tag number where seclusion identified separately)
- 13. Reducing Use ofSeclusion 13 • “Learning from EachOthers – Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health”* • Tools and forms in appendix • Tool for behavioral health patients • Published in 2003 by many organizations including: • American Psychiatric NursesAssn. – NationalAssociation of Psychiatric Health Systems (NAPHS) with support ofAHA • See NAPHS andAHA guiding principles1 1 www.naphs.org;www.apna.org, www.psych.org, or www.apna.org, http://www.naphs.org/catalog/ClinicResources/index.html
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- 15. Restraint and Seclusion154 15 • All patients have a right to be free from unnecessary physical or mental abuse, and corporal punishment • Only used: • When necessary • Not as coercion, discipline, convenience or retaliation • For patient safety • Discontinued at earliest possible time
- 16. Reasons to Restrain •Check all that apply: • Unable to follow directions for safety • Aggressive • Disruptive/combative • Self injury • Interference with treatments • Removal of medical devices • Other: 16
- 17. MedicalCondition – Needfor Restraint 17 • If the assessment indicates a need to protect the patient from harm – must use least restrictive intervention • Can consider restraint • Weigh risk of using restraint against risk presented by behavior • Request by patient/family not sufficient basis • If need confirmed – practitioner must determine type with least risk and most benefit
- 18. Documentation 18 • Staff mustdemonstrate restraint is least restrictive • Through documentation • Protects patient • Based on assessments • Assessments and documentation must be ongoing to show continued need • Once a day may not be sufficient – clinical condition changes over time
- 19. Use ofWeapons 19 • Useof weapons in application of restraint or seclusion not considered a safe, appropriate health care intervention • Pepper spray – Mace – Nightstick –Tasers –Cattle prods – Stun guns – Pistols • Security can carry per policy,State/Federal law • Not considered health care intervention • Is a law enforcement action • CMS does not support use of weapons by any hospital staff as a means of subduing a patient to place in restraint/seclusion
- 20. Not Covered ByRule – Law Enforcement • What: • Handcuffs • Manacles • Shackles • Other chain-type restraint devices • Not hospital staff: • Not considered safe nor appropriate interventions • Ensure P&P mention • Who: • Non-hospital • Employed • Contracted law enforcement • Purpose • Custody • Detention • PublicSafety 20
- 21. 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 21
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- 23. Impact of Restraint 23 •TJC: 40% of restraint-related deaths were caused by unintended asphyxiation during restraint • Creates a negative response to the situation and can be humiliating to the patient • Can be physically and emotionally traumatizing to the staff involved • It impacts the trust between the patient and the staff • Restraint and seclusion should be a last resort • And only done to protect the patient or the staff
- 24. Boarding Behavioral HealthPatients 24 • Many hospitals board behavioral health patients pending an inpatient psyche bed due to a shortages • Important to ensure that the patient is in a safe room to prevent inpatient suicide • Many EDs have separate area to house these patients • Free guide on how to create a safe room called the Behavioral Health DesignGuide, at FacilityGuideline Institute* • Includes self assessment tool
- 25. 189 189 The End Questions??? •LauraA.Dixon, Esq. • BS, JD, RN,CPHRM • President, Healthcare Risk Education, and Consulting, LLC • 303-955-8104 • ldesq@comcast.net Register Now