Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
The Harmony Healthcare International (HHI) Team is seeing a need to review the definition of Physical Restraints. Surveyors across the country have a heightened focus on restraint reduction so this topic is a priority. First and foremost, Harmony Healthcare International (HHI) recommends a comprehensive facility wide review to determine whether the devices (such as crisscross belts and low bed) are:
- Properly Assessed for each resident and
- Appropriately Identified as a restraint (per regulatory definition).
Physical Restraints are associated with many negative outcomes, including but not limited to:
- Higher Propensity of Injury
- Poor Circulation
- Weak Muscles and Bones
- Pressure Ulcers
- Poor Appetite and Infections
The healthcare industry strives to reduce and eliminate the use of restraints. Restraints impede a patient's ability to be mobile and may also cause isolation and other psycho-social issues.
It is important to identify any devices that could restrain a patient. Once a restraining device is identified, immediate care planning for patient safety as well as the reduction or elimination of the restraint is required.
State Operation Manual: Defining Physical Restraint
Per the State Operations Manual, Appendix PP, a physical restraint is defined as
"Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body" (SOM, Section 483.13(a)).
The State Operations Manual (SOM) further states that:
"The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.”
- The device itself does not determine the criterion for classification as a restraint.
- The effect of the device on the resident determines the classification as a restraint.
The same device may be a restraint for one patient but not another. This depends on the individual resident’s condition and circumstances.
Harmony Healthcare International (HHI) recommends the completion of a Restraint Assessment to formally and effectively identify if the device is considered a restraint.
All care plans begin with a restraint assessment which identifies:
- Interventions to minimize or eliminate the medical symptom(s) causing the need for the restraint.
- Any underlying causes for the medical symptom should also be addressed.
- Risks related to restraint use should be identified, and the Care Plan that results from this assessment should include plans to reduce or eliminate the restraint as soon as possible.
- The schedule for when the restraint is applied and released.
Care Plan for Physical Restraints
Harmony Healthcare International (HHI) recommends Daily Documentation within the medical record to support that the Care Plan. A Care Plan includes:
- Resident Specific
- Rationale for using of the device.
- States if the device is a restraint.
- Risks that the device poses for the patient.
- A Plan to Reduce or mitigate those risks.
- Reasons why Prior Attempts to reduce the restraint are
Survey Process of Physical Restraints
Surveyors are instructed to determine if the restraint is used for a medical symptom, and to evaluate if the medical symptom is clearly documented in the medical record.
The surveyor will determine if the facility properly assessed the patient, including:
- If there is another alternative such as providing rehabilitative/restorative care, providing meaningful diversional activities,
- Attempts to prevent an avoidable decline that was caused using the restraint,
- If the patient or patient representative has been informed of the risk/benefit of the use of a restraint as well as possible negative outcomes associated with restraint use.
- A surveyor will evaluate if the clinical decision making included restraint reduction and/or attempts at restraint elimination.
For a restraint to be used, the following criteria must be reviewed:
- Medically necessary to treat a medical symptom;
- Not a mechanism to discipline a resident or for staff convenience in the absence of a medical symptom;
- Least restrictive device possible, in use for the least amount of time per day possible; and
- Existing Care Plan addressing decrease usage of the restraint or the eventual removal of the restraint.
During the Annual Health Inspection, surveyors are instructed to review residents with restraints. The below Critical Pathway is a valuable reference for the team.
The Critical Elements Pathway for Restraint Use
- Do not rely on facility documentation alone to determine whether the device or practice is a restraint.
- It is a surveyor's determination whether the device or practice is restraining the resident, despite contrary facility documentation.
- If the medical record states that the device (or practice) is not a restraint, but the surveyor’s investigation finds otherwise, the device or practice is a restraint.
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