Ftag of the Week – F605 Right to be Free from Chemical Restraints (Pt. 3)

In this week’s CMSCG “Ftag of the Week,” post, we will finish our review of F605 Right to Be Free from Chemical Restraints, a potentially high-risk area for providers. As you can tell from the actual citation examples we have provided in Part 1 and Part 2 of this blog series, residents can experience significant negative outcomes if overmedicated. Use of medications for the purposes of staff convenience or for discipline can result in the resident sleeping during hours where he/she would not normally be sleeping (which can be observed by a surveyor), limiting his/her functional capacity and/or resulting in the resident appearing sedated, confused or subdued. The resident can also experience a decline in continence level, physical functioning, skin integrity and even weight loss – lots of reasons to review your facility’s practices to ensure residents are appropriately medicated. This is, in part, why the Centers for Medicare & Medicaid Services (CMS) continues to emphasize the use of unnecessary psychotropic meds. In order to differentiate between appropriate medical use and a chemical restraint, the medical record needs to reflect some important information, which is what we will discuss in this post.

Medical Record Documentation

According to Appendix PP of the State Operations Manual, the resident’s record needs include several pieces of documentation to justify use of a medication. These include:

  • Adequate indication for use of the medication – as discussed in prior posts, the indication for use of any medication that is ordered for a resident must be identified and documented in the resident record.
  • Evidence of adequate monitoring for the medication’s effectiveness in treating the specific condition it has been prescribed for.
  • Documentation of any excess dose/ duration that the medication was administered and any adverse consequences resulting from administration
  • If a resident has orders for a PRN psychotropic med, the medication is not administered unless it is necessary to treat a diagnosed, specific symptom, unless clinically contraindicated. PRN orders to address emergency medical conditions, such as delirium, would not be considered a chemical restraint, per the Interpretive Guidance (IG). However, the dosage cannot exceed what has been prescribed, and if the medication is not effective initially, the ordering practitioner needs to be contacted for re-assessment of the resident’s condition and re-evaluation of the interventions in place.
  • Evidence of a Gradual Dose Reduction (GDR) and behavioral interventions, unless contraindicated, for a resident who is prescribed a psychotropic drug – Don’t forget about that second part. In our medical record reviews for clients, we all too often find that there is no evidence of behavioral interventions care planned, attempted or documented for residents receiving psychotropic meds, including by the medical practitioner.

What’s Considered a Chemical Restraint

Rather than use actual survey citations for this post, we’re going to review the Appendix PP guidance related to facility practices that CMS feels are indicative of a medication being used as a chemical restraint for staff convenience or discipline. When you read this list, you may recognize some of these practices occurring in your own building – that could be very problematic.

  • A medication is being administered per a resident representative’s request to “calm down” the resident
  • Staff have recommended to the prescribing practitioner that the resident is displaying behaviors such as wandering into other resident’s rooms, and if medication was administered, this would prevent the behavior
  • Staff administer medication to sedate/subdue a resident by restricting the resident to a lying/ seated position to prevent him/her from continually trying to leave the unit or wander in and out of resident rooms on the unit
  • Staff administer medication to a resident who is resistant to bathing and physically aggressive towards staff, without evidence of a medical symptom for use or evidence of alternatives attempted or reassessment of the resident
  • A medication is administered to a resident who continually calls out, without evidence of other alternative interventions attempted
  • Staff administer medication to sedate a resident who continually requests staff assistance or continually puts the call bell on

Hopefully you’re getting the idea that your behavior management efforts likely need a review to ensure staff are not relying on medications to “manage” your residents’ behaviors.

The final example is of particular concern given the national staffing crisis. The IG notes that if staff administer medications with a sedative effort or an effect to subdue the resident because there is insufficient staffing, this would be considered a chemical restraint.

Keep an eye on what’s going on in your facility. Frustrated staff who are rushed due to call outs and working doubles may be tempted to cut corners when it comes to behavior management. Also, while you are looking at potential chemical restraints, keep in mind that your consultant pharmacist should be reporting on medication irregularities in their monthly MRR (F756) and that your facility has the responsibility to ensure that each resident’s drug regimen is free from unnecessary drugs, including psychotropics (F757 and F758).

A hard look should be taken at the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway to ensure that chemical restraints do not show up on the survey team’s radar.


CMS Compliance Group, Inc. is a nursing home consulting firm that assists providers with quality improvement and compliance initiatives, including developing and implementing effective behavior management programs. Our experienced consultants can also provide education to your staff to help reduce reliance on the use of medications to address behavioral concerns. Contact CMSCG to learn more, or visit our Nursing Home Consulting Services webpage to understand more about how we can partner with your organization.


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