Long-Term Care Survey Alert

Ready for a quick restraint refresher?

Physical restraint use is one of those survey hot spots that continues to sizzle. Most recently, the Centers for Medicare & Medicaid Services published a list of several thousand facilities with high scores on the publicly reported high-risk pressure ulcers and/or the physical restraint quality measures. Quality Improvement Organizations will be offering facilities help with either or both quality issues (for details, see the last Long-Term Care Survey Alert).

The survey reality: Count on surveyors homing in on your physical restraint quality indicator/quality measure. In addition to quality improvement efforts aimed at reducing or eliminating physical restraints, consider these quick pointers.

1. Know how the restraint QI/QM works. Only residents who had a restraint daily (P4c, P4d or P4e = 2) during the seven-day lookback will trigger the QI/QM. P4c is trunk restraints, P4d, limb restraints, and P4e chair prevents rising. Admission assessments are excluded. If the resident had a restraint less than daily, code a "1."

Also: Be aware that relying strictly on the QI/QM to identify residents with less than daily restraint use won't work.

2. Correct the top cause of undercoding restraints. Missouri RAI state coordinator Joan Brundick, RN, finds the top cause to be a lack of understanding about what meets the definition of a restraint. "If the device keeps the person from falling, for example, the staff thinks they don't have to code the device as a restraint" in Section P, she says.

The reality: The RAI manual defines a physical restraint 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."

Key point: "You have to look at the person's normal functional abilities prior to using a device -- and how that device affects the person's functioning," Brundick says.

Here are two key questions to ask, according to a CMS Webcast on restraints:

• Is this a device attached to or adjacent to the resident's body that the person cannot remove easily?

• Does the device restrict the resident's freedom of movement or normal access to the person's body?

Know the clarifications: A June 22, 2007, survey and certification memo clarified that freedom of movement means "any change in place or position for the body or any part of the body that the person is physically able to control." "Remove easily" means that the resident can intentionally remove the manual method, device, material or equipment in the same manner as staff applied it. For example, the resident can put the siderails down rather than climbing over them -- or can intentionally unbuckle a buckle. Consider the resident's physical condition and ability to accomplish an objective, such as transferring out of a chair or getting to the bathroom in time.

Pay careful attention to bedrails: They won't trigger the restraint QI/QM, but surveyors will no doubt be checking to see if they act as a restraint or hazard in an individual case. "Nurses will frequently code siderails as a restraint only if that's why staff put the siderail up," says Nathan Lake, RN, BSN, MHSA, an MDS and long-term care expert in Seattle. Instead: Code siderails based on the impact on the resident, not the staff's intention for using them. (See the related reader question on the next page.)

3. Target the top reason for overuse of restraints. The biggest mistake Lynda Mathis, RN, CLNC, sees people make in that regard is "a knee-jerk response" where the staff feels as if they have to do something immediately to protect a resident or residents. So they don't do a full root-cause analysis to figure out the underlying reason someone fell or became agitated and struck out at someone else, etc., notes Mathis, a consultant in Conway, AR.

"When we restrain a resident with dementia, it means we haven't figured out how to meet his needs and protect him from injury without tying him down."