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s mentioned in previous articles regarding systems, protocols should be established first utilizing regulations and current standards of care or practices. This article will focus on restraint usage in nursing homes and the Centers for Medicare and Medicaid Services (CMS) Federal Regulation Tag F 221, which addresses the use of physical restraints. At a minimum, the facility should refer to this regulation when establishing a facility system for use of restraints. The facility should establish a protocol that provides guidelines for employees to follow for restraint use.
       If your facility was surveyed in regard to restraints, how would your staff respond, or the medical record reflect, in regard to the following probes listed in the Guidance to Surveyors for F tag 221?
1. What are the medical symptoms that led to the consideration of the use of restraints?
2. Are these symptoms caused by failure to:
       a. Meet individual needs in accordance with the resident assessments?
       b. Use rehabilitative or restorative care?
       c. Provide meaningful activities?
       d. Manipulate the resident’s environment including seating?
3. Can the cause of the medical symptoms be eliminated or reduced?
4. If the causes cannot be eliminated or reduced, has the facility attempted to use alternatives in order to avoid physical decline associated with restraint use?
5. If alternatives have been tried and deemed unsuccessful, does the facility use the least restrictive restraint for the least amount of time?
6. Did the resident or legal surrogate make an informed choice about the use of restraints? Were risks, benefits, and alternatives explained?
7. Does the facility use the physical restraint Resident Assessment Protocol (RAP) to evaluate the appropriateness of restraint use?
8. Has the facility reevaluated the need for the restraint, made efforts to eliminate its use, and maintained the resident’s strength and mobility?
       What tools does your facility utilize to assure all of the above are considered when it is necessary to use restraints? Is the system you have consistently implemented and also consistently monitored by your quality assurance program?
       Minimally, most facilities would have the following to be sure they met the federal requirements for restraint use:
• Restraint policies and procedures
• Restraint assessment form
• Restraint consent form
• Restraint risk and benefit form (if not included on another form).
       In addition, facilities must be sure they have systems that ensures:
1. Physician order is written
2. Inclusion on care plan
3. Evaluated for least restrictive
4. Reevaluated on regular basis and continued need validated
5. Free time is planned and routinely administered
6. Deterioration in physical or mental or psychosocial well being is not related to restraint usage.

Beware of Pitfalls

       Often, facilities have complete and adequate policies and procedures but no method or system to assure the policies and procedures are being followed.
       Many facilities do not have ongoing quality assurance audits to be sure all the “pieces of the puzzle” stay in place. Often, there is paper compliance without proper follow up from information placed on paper.
There are many companies offering forms and systems—before adapting, be sure these meet the needs of your facility and your staff understand how, when, and why to use the form.
       The following are a summation of common deficiencies cited regarding restraint usage:
• No reduction attempted
• Free time not given as stated on care plan
• No consent form for use of restraint
• Alternatives not attempted prior to restraint use
• Restraint on resident not same as restraint ordered
• Medical symptom for use of restraint not documented
• Restraint not evaluated for least restrictive device.
       Consistently following a mandatory system/protocol for restraint use will help avoid deficiencies while assuring quality care for the resident. Additionally, a simple quality assurance tool, such as that shown in Figure 1 could have avoided many of these citations had they been identified and corrected in a timely manner.
       In almost 100 percent of all facility deficiencies cited, the New Day Professional Services staff members identify problems with systems. Either the system/protocol has not been established to include all the regulatory and standard of practice criteria or facility staff has not consistently followed the system/protocol of the facility. Usually, with appropriate updating of policies and procedures, training, and establishment of quality monitoring tools, citations are corrected and remain corrected—as long as the facility assures systems remain updated and compliance is expected and monitored.
       New Day Professional Systems develops policies, procedures, protocols, and tools to assist facilities in maintaining compliance. For more information, visit http://newdayprofessionals.com or call 803-796-7835.