Ftag of the Week – F604 Right to be Free from Physical Restraints (Pt. 1)

The newest “Ftag of the Week” on the CMSCG Blog is F604 Right to be Free from Physical Restraints, which is part of the Freedom from Abuse, Neglect, and Exploitation regulatory group. The intent of this regulation is to prohibit the use of physical restraints to unnecessarily inhibit a resident’s freedom of movement or activity, prohibit the use of physical restraints for convenience or discipline, and to ensure that the facility limits use of physical restraints to situations where a resident’s medical symptoms may indicate the use of a restraint would be appropriate.

What’s Required in the Regulation

This regulation requires nursing homes to ensure that residents are free from physical or chemical restraints used for the purposes of convenience or discipline and that are not required for treating a resident’s medical symptoms. If physical restraints are being used for medical symptoms, they must be the least restrictive alternative and be used for the least amount of time possible, with on-going, documented re-evaluation of the need for restraints.

What is a Physical Restraint?

F604 defines a “physical restraint” as any manual method, physical or mechanical device, equipment or materials that meets all these criteria:

  • Is attached to or adjacent to the resident’s body and
  • Cannot be easily removed by the resident and
  • Restricts the resident’s freedom of movement or normal access to his/her body.

The regulation also defines what “removes easily” means. It means that whatever restraint is in place can be removed intentionally by the resident in the same way that it was applied by staff.

The Interpretive Guidance (IG) notes that the resident’s physical condition and/or his/her cognitive status can be contributing factors in whether the resident has the ability to remove the restraint. A lap belt may be considered a restraint for a resident who cannot easily release the belt buckle, but for another resident who is capable of intentionally releasing the buckle, this may not be considered a restraint.

Restraint-Related Risks and Impact on Residents

A primary reason that the use of physical restraints has received so much attention from regulators in recent years is that their use has been found to have many risks and the potential for negative side effects that outweigh the benefits of use. There are both potential physical risks and negative psychosocial outcomes related to the use of physical restraints and providers need to ensure that if they are used, they are appropriately used to minimize risks and negative outcomes.

Per the Interpretive Guidance (IG), possible risks due to the use of physical restraints include:

  • Accidents, including falls, entrapment or strangulation.
  • Injury when the resident attempts to free him/herself.
  • Decline in the resident’s physical functioning that results in increased ADL assistance required, decline in range of motion, increased risk for development of contractures and/or impaired balance and strength.
  • Skin breakdown or skin integrity issues
  • Respiratory complications

In addition to the above-mentioned risks, the use of physical restraints can also have psychosocial impact on the resident, including:

  • Loss of dignity, self-respect and identity
  • Agitation or aggression
  • Development of delirium
  • Dehumanization
  • Feeling of fearfulness or panic
  • Feeling threatened
  • Feeling of shame
  • Feeling of imprisonment
  • Feeling of restricted freedom of movement

The potential for these and other risks and negative outcomes makes it important for facilities to ensure that the use of any physical restraint is limited only to circumstances warranted by the resident’s medical symptoms.

On Survey

At the start of survey, providers will be giving information about physical restraint use to the survey team on the CMS-802 Matrix. The Matrix requires that residents who have a physical restraint in use are identified.

Do not forget, the survey team will already have looked at QM reports as part of its offsite preparation, so if the facility flags for an unacceptable level of restraints, then the survey team’s radar will be up.

Do not forget, the survey team will already have looked at QM reports as part of its offsite preparation, so if the facility flags for an unacceptable level of restraints, then the survey team’s radar will be up. Regardless, surveyors will use observations, interviews and record reviews to gather information and identify potential concerns related to the use of restraints. This includes physical restraints that were not coded on the MDS – and this could be potentially problematic. The surveyors will be looking at:

  • Use of a physical restraint – including whether the facility identified the device as a restraint – how long it has been used, duration of use and what alternatives were attempted.
  • The information provided to the resident/representative regarding the use of the restraint.
  • Whether the use of the restraint reflects the resident’s preferences/choices.
  • Whether the physical restraint is being used for, or has the effect of, staff convenience or discipline.
  • Physical and psychosocial outcomes from restraint use.

Surveyors will use the Physical Restraints Critical Element Pathway to investigate any concerns related to the following:

  • A resident’s record reflects the use of a physical restraint.
  • An allegation of inappropriate use of a physical restraint has been received.
  • If the resident or other individual reports that a restraint is being used on the resident.
  • If the surveyors observe a device or practice that restricts/potentially restricts the resident’s freedom of movement. This includes observations of position change alarms.

In our next few posts in our CMSCG Ftag of the Week Blog series, we will look at F604 in more detail, including the requirements for assessing, care planning and documenting the use of a physical restraint, when restraints are used for convenience or discipline purposes, and provide some actual survey citations to help explain what can go wrong and a provider ends up being cited under F604, which, don’t forget, is one of the Abuse Ftags.  Physical restraint use is an area that requires ongoing monitoring to ensure that the number of restraints being used doesn’t creep up. 

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