In our continuing look at MDS 3.0 we devote this article to looking at the issue of restraint management in nursing home residents. This of course is a touchy subject because part of the long-time perception of nursing homes is that residents are restrained all the time. And while that is not true, surprisingly inappropriate restraints are still employed. MDS 3.0 seeks to clarify this issue.
The Centers for Medicare and Medicaid Services (CMS) is committed to reducing unnecessary physical restraint in nursing homes and ensuring that residents are free of physical restraints unless deemed necessary and appropriate as permitted by regulation. Proper interpretation of the physical restraint definition is necessary to understand if nursing homes are accurately assessing devices as physical restraints and meeting the federal requirement for restraint use.
While a restraint-free environment is not a federal requirement, the use of restraints should be the exception, not the rule according to CMS. Restraints should not be used:
- if imposed for discipline or convenience
- if not required to treat the resident’s medical symptoms.
No to Restraints
Research and standards of practice show that restraints have many negative side effects and risks.
- Restraints limit mobility and increase the risk for a number of adverse outcomes.
- Restraints can lead to functional decline, agitation, diminished sense of dignity, depression, and pressure ulcers.
- Residents who are cognitively impaired are at a higher risk of entrapment and injury or death.
- The risk of restraint-related injury and death is significant.
Assess Before Restraining
Prior to using any restraint you must assess the resident to properly identify the their needs and the medical symptom(s) that the restraint is being employed to address. If a restraint is needed to treat the resident’s medical symptom, the nursing home is responsible for assessing the appropriateness of that restraint. CMS encourages, to the extent possible, gradual restraint reduction because there are many negative outcomes associated with restraint use.
The following guidelines for assessment are provided by CMS.
- Review the resident’s medical record to determine if physical restraints were used during a 7-day look-back period.
- Consult the nursing staff to determine the resident’s cognitive and physical status/limitations.
- Observe the resident to determine the effect the restraint has on the resident’s normal function.
- Evaluate whether the resident can easily and voluntarily remove the device, material, or equipment. If the resident cannot, continue with the assessment to determine whether the device restricts freedom of movement or the resident’s access to his or her own body.
- Determine if the device, material, or equipment meets the definition of a physical restraint as clarified below. Remember, the decision about coding any device, material, equipment, or physical or manual method as a restraint depends on the effect the device has on the resident.
Restraints can include bed rails used as positioning devices even though they may improve the resident’s mobility in bed.
Trunk restraints may be any device or equipment or material that the resident cannot easily remove such as a vest or waist restraints or belts used in a wheelchair.
Limb restraints include any device or equipment or material that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg). Included in this category are mittens.
Chairs that prevent rising include any type of chair with a locked lap board, that places the resident in a position that restricts rising, or a chair that is soft and low to the floor. The above is a partial list.
Note that if the resident can remove the restraint, i.e., seat belt, easily and upon request it is not considered a restraint.
- Any device, material, or equipment that meets the definition of a physical restraint must have physician documentation of a medical symptom that supports the use of the restraint, a physician’s order for the type of restraint and parameters of use, and a care plan and a process in place for systematic and gradual restraint reduction.
Addressing the Underlying Symptom
Physical restraints as an intervention do not treat the underlying causes of medical symptoms. Therefore physical restraints should not be used without also seeking to identify and address the physical or psychological condition causing the medical symptom.
Physical restraints may be used as a symptomatic intervention when they are immediately necessary to prevent a resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment when no other less restrictive or less risky interventions exist.
The medical symptoms that support the use of restraints must be documented in the resident’s medical record, ongoing assessments, and care plans. There also must be a physician’s order reflecting the use of the restraint and the specific medical symptom being treated by its use.
Ultimately, identification of medical symptoms should assist in determining whether the symptom can be improved using other, less restrictive interventions.
The Case for FallsAccording to CMS, although restraints have been traditionally used as a fall prevention approach, they have major drawbacks and can contribute to serious injuries. Falls do not constitute self-injurious behavior nor a medical symptom supporting the use of physical restraints. In fact, they maintain, in some instances, reducing the use of physical restraints may actually decrease the risk of falling.
Honoring Family Requests
While a resident, family member, legal representative, or surrogate may request use of a restraint, the nursing home is responsible for evaluating the appropriateness of that request, just as they would for any medical treatment. As with other medical treatments, such as the use of prescription drugs, a resident, family member, legal representative, or surrogate has the right to refuse treatment, but not to demand its use when it is not deemed medically necessary.
This from the CMS Statute “...the legal surrogate or representative cannot give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident’s medical symptoms. That is, the facility may not use restraints in violation of regulation solely based on a resident, legal surrogate or representative’s request or approval.”
If you haven’t figured it out already, the use of restraints is frowned upon. You can’t ask for forgiveness later. This is a serious issue.
You should exhaust alternative treatments and less restrictive measures before a restraint is employed to treat the medical symptom, protect the resident’s safety, help the resident attain or maintain his or her highest level of physical or psychological well-being and support the resident’s goals, wishes, independence, and self-direction.
Source: CMS’s RAI Version 3.0 Manual