CMS Standards Regarding the use of Restraints and Seclusion

Answer the following questions using the link to CMS regulations in resources.

What is the definition of a restraint?

Answer: It is any manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces ability of a patient to move his or her arms,
legs, body, or head freely.

What items or procedures are not considered a restraint even though they may
restrict joint mobility?
Answer:

When are side rails not considered a restraint?

Answer: Side rails are not considered a restraint when used to both prevent and
protect a patient from falling out of bed, as in the following situations: patient is being
transported on a stretcher, recovering from anesthesia, sedated, experiencing
involuntary movement (i.e., seizures), or lying on certain therapeutic types of beds.
They are also not considered a restraint if the patient is able to intentionally and
independently put down the side rails in the same manner as which they were applied
by the staff and they do not immobilize or restrict a patients freedom of movement in
any fashion.

Under what broad circumstance (patient-centered) is it deemed appropriate that

restraints can be used?
Answer:
Restraint or seclusion may only be imposed to ensure the immediate physical
safety of the patient, a staff member, or others and must be discontinued at the
earliest possible time.

What procedures or staff actions must take place before restraints can be applied?
Answer:
In collaboration with a registered OTR, COTAs may assess the need for restraints,
consult with staff about alternatives to restraint, and provide intervention to eliminate
restraint use. The type or technique of restraint used must be the least restrictive
intervention that will be effective to protect the pt., staff member, or others from harm.
Once the need for intervention is documented and an OT order has been received,
the OTR/COTA team performs an evaluation. Specific assessments of posture,
alignment, balance, strength, and visual acuity are necessary. Assessments of head
control, trunk stability, upper extremity support, and the ability to self-propel are added
to evaluate seating needs.
Perceptual and cognitive assessments should be included only as appropriate.

Practitioners should not embarrass or agitate cognitively impaired elders by assessing

areas already documented as deficient.
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To what settings do the CMS regulations on restraints apply?

Answer: The requirements apply to all participating hospitals including short-term,
psychiatric, rehabilitation, long-term, childrens and alcohol/drug treatment facilities.

Can restraints be used if a family member insists on the restraints to prevent injury to
the elder?
Answer: No, according to the Geri Book, pg 179 (older version): Medicare and
Medicaid sanctions such as decertification and even delicensure of the facility can
occur from imposing restraints rather than removing them. Regardless of a family
member/ care givers feelings it is not allowed.
(by Taylor Priester) (I couldnt remember my number so I did this one)

What are possible indicators that physical restraints are being used for staff
convenience, inadequate training or inadequate numbers of staff?
Answer: Restraint or seclusion may not be used unless the use of restraint or
seclusion is necessary to ensure the immediate physical safety of the patient, a staff
member, or others. The use of restraint or seclusion must be discontinued as soon as
possible based on an individualized patient assessment and reevaluation. Restraints
must be least restrictive and assessed frequently to make sure they are appropriate.
Overuse, over-restriction, or patients are unable to get restraints off by self. When
restraint use is not part of a plan of care. Restraints are improperly used.This is
Jerrys answer: (I dont know who wrote the top portion of this answer) If a site
surveyor sees patterns of restraints during certain times in a facility, such as
during shift changes, transportation of clients, or low staffing (holidays,
meetings) this is a good indicator that restraints are being used for
convenience and are not being used properly.

What are possible indicators that chemical/pharmaceutical restraints are being used
for staff convenience, inadequate training or inadequate numbers of staff?
Answer: A drug or medication that is not being used as a standard treatment for the
patients medical or psychiatric condition, and that results in restricting the patients
freedom of movement would be a drug used as a restraint. For example, the staff
asks the physician to order a high dose of a sedative for a dementia patient who is
having sundowners syndrome, causing him to wander, pace the floors, or exhibit
other nervous behaviors, to knock him out and keep him in bed because he finds
the patients behavior bothersome.

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Can state law supersede CMS regulations on restraints?

Answer:Yes, CMS regulations on restraints can be superseded by State law that is
more restrictive.

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What is the definition of seclusion?

Answer: - The the involuntary confinement of a person in a room or an area where

the person is physically prevented from leaving.
https://www.cms.gov/Regulations-andGuidance/Legislation/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf
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What elements must be in a doctors order for restraint or seclusion?

Answer: The order should include the reason for the use of restraint/seclusion, type of
restraint, and the duration of the restraint/seclusion.
Time limits for restraint or seclusion for up to a maximum total of 24hrs.:
- 4hrs. for adults ages 18 and over
- 2 hrs. for children and adolescents 9 to 17 years of age
- 1hr. for children under the age of 9
*Not sure who had this question, but I (Jenny) went ahead and answered.

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What should be included in the medical record after the use of restraint or seclusion?
Answer:The 1-hour face-to-face medical and behavioral evaluation if restraint or
seclusion is used to manage violent or self-destructive behavior; (When restraint
or seclusion is used to manage violent or self-destructive behavior, the 1 hour face-toface medical and behavioral evaluation must be documented in the patients medical
record.)
A description of the patient's behavior and the intervention used.
(Documentation that must be included in the patients medical record when the patient
is restrained or secluded includes a description of the patients behavior and the
intervention used. The patients behavior should be documented in descriptive terms
to evaluate the appropriateness of the interventions used. The documentation should
include a detailed description of the patients physical and mental status
assessments, and of any environmental factors (e.g., physical, milieu, activities, etc.)
that may have contributed to the situation at the time of the intervention.)
Alternatives or other less restrictive interventions attempted (as applicable).
( The use of restraint or seclusion must be selected only when less restrictive
measures have been judged to be ineffective to protect the patient or others from
harm. It is not always appropriate for less restrictive alternatives to be attempted prior
to the use of restraint or seclusion. When a patients behavior presents an immediate
and serious danger to his- or herself, or others, immediate action is needed. For
example, when a patient physically attacks someone, immediate action is needed.
While staff should be mindful of using the least intrusive intervention, it is critical that
the intervention selected be effective in protecting the patient or others from harm. )
The patient's condition or symptom(s) that warranted the use of the restraint or
seclusion. (A comprehensive, individualized patient assessment is necessary to
identify the most appropriate intervention to effectively manage a patients condition
or symptom(s). When using a restraint or seclusion intervention, the patients
condition or symptom(s) must be identified and documented in the patients medical
record. )
The patient's response to the intervention(s) used, including the rationale for
continued use of the intervention.

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Who must complete the face to face assessment when restraints or seclusion have
been used and in what timeline must this assessment happen?
Answer: When restraint or seclusion is used to manage violent or self-destructive
behavior, a physician or other LIP, or a registered nurse (RN) or physician assistant
(PA) trained in accordance with the requirements specified, must see the patient faceto-face within 1-hour after the initiation of the intervention. The evaluation includes
both a physical and behavioral assessment of the patient that must be conducted by a
qualified practitioner within the scope of their practice. An evaluation of the patients
medical condition would include a complete review of systems assessment,
behavioral assessment, as well as review and assessment of the patients history,
drugs and medications, most recent lab results, etc.

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What is being assessed in the face to face assessment?

Answer: