After a minor detour over the past few weeks due to the Centers for Medicare & Medicaid Services (CMS) releasing an Interim Final Rule a few weeks ago, that led to a new regulation, F887 COVID-19 Immunizations, and updated vaccine reporting requirements for F884 Reporting – National Health Safety Network, we are heading back to finish up our Ftag of the Week – F604 Right to be Free from Physical Restraints (view Part 1 of our CMSCG Ftag of the Week for F604 here). In this week’s post, we will review what the regulation says about the use of physical restraints for convenience or discipline, two areas where providers definitely do not want to be cited, as well as what needs to happen when a restraint is being considered for a resident.
Physical Restraints for Convenience or Discipline
Two important concepts in the regulation are “convenience” and “discipline,” both of which are strictly prohibited reasons for use of a physical restraint.
“Convenience” is the result of any activity that has impact’s the resident’s behavior to the point that it requires less effort or care for the resident and is not in the resident’s best interest.
“Discipline” is an action that is taken for the purpose of punishing or penalizing a resident.
The IG was significantly expanded regarding this section of F604 when the RoPs were updated a few years ago, particularly with a list of reasons that staff may not use restraints for their convenience or to discipline a resident. Nursing homes may not:
- Seek permission from the resident or resident representative to use restraints when the restraint is not necessary to treat the resident’s medical symptoms.
- Inform a resident or representative that a restraint could be beneficial to the resident for the purposes of preventing a fall or safeguarding a resident who may unsafely wander into other residents’ rooms.
Falls do not constitute a medical symptom or self-injurious behavior that warrants the use of physical restraints.
It is worth mentioning that the IG specifically states that falls do not constitute a medical symptom or self-injurious behavior that warrants the use of physical restraints. CMS notes that it has found no evidence that physical restraints will prevent or reduce falls, and states that physical restraints can have more serious drawbacks and/or contribute to serious injuries when a resident who is physically restrained experiences a fall. So where do you stand with the use of mitts and self-injurious behaviors? What are you doing for the resident who has attempted to self-decannulate on multiple occasions?
Scenarios where physical restraints of any kind are used, either intentionally or unintentionally by staff, for reasons that are not to treat a specific medical symptom, indicate use for convenience or discipline.
Examples of Staff Using Physical Restraints for Convenience
The IG includes multiple reasons that staff could use physical restraints for convenience:
- Lack of staff education regarding alternatives to physical restraints for preventing falls and accidents.
- Belief that new or agency staff do not know the resident, how to approach the resident and/or how to address a resident’s behavioral symptoms or care needs, so they decide to use physical restraints.
- Staff alerting Administration that there are not enough staff on a particular shift/ over the weekend and staffing levels were not increased.
- Family has requested that the resident be restrained, particularly during busy times when staff may need to also assist other residents.
- When care is being provided to a cognitively impaired resident who becomes combative and staff hold the resident’s arms/legs down to complete the care.
- Staff feel a resident does not exercise good judgement and will not wait for staff assistance to use the bathroom or otherwise not understand his/her physical limitations.
- Staff state they are too busy to monitor the resident because their workload is too great.
Examples of Staff Using Physical Restraints for Discipline
The IG also includes reasons that staff may decide to use physical restraints for discipline:
- A staff member lacks respect for, or has negative feelings towards, a resident and restraints the resident to “teach a lesson.”
- Staff become frustrated by a resident’s wandering behavior and restrain the resident in a wheelchair or otherwise restrict his/her movement.
Now that we have looked at some scenarios where the use of a restraint would be inappropriate, it’s time to look at how and when the use of a physical restraint may be warranted.
Assessing, Care Planning and Documenting the Use of a Physical Restraint
As a reminder, the use of physical restraints is limited to only the circumstances where a resident has medical symptoms that warrant the use of a restraint. It is critical, if this is the case, to ensure that the resident’s needs have been assessed, appropriately care planned, and there is comprehensive documentation to support the need for use.
The use of physical restraints is limited to only the circumstances where a resident has medical symptoms that warrant the use of a restraint.
Documentation must include:
- Medical symptom being treated.
- Order for the use of the specific type of restraint
- Length of time the restraint is anticipated to be used to treat the medical symptom.
- Who is allowed to apply the restraint.
- Time and frequency of restraint release.
- Type of specific direct monitoring and supervision that will be provided during use of the restraint, along with documentation of the actual monitoring.
- How the resident can request staff assistance.
- How resident needs will be met when the restraint is in use.
- Interventions that were attempted, but were ineffective, for treating the resident’s medical symptom.
- Development and implementation of interventions to prevent and address any risks related to restraint use.
- Evidence that the resident/ representative was provided information on the potential risks and benefits of all options that are being considered. This includes alternatives to restraints, use of a restraint, as well as not using a restraint.
- Who is responsible for determining that the medical symptom has been resolved in order to discontinue use of the restraint.
- Ongoing re-evaluation for the need of a restraint and its effectiveness in treating the resident’s medical symptoms.
In Part 3 of our Ftag of the Week for F604 Right to be Free from Physical Restraints, we will look at some special circumstances, as well as requests and refusals for restraints, as well as some actual citations.
