Long-Term Care Survey Alert

Make sure surveyors don't reach the wrong conclusion about a self restraint.

Picture this: A surveyor asks a resident to remove a self-release belt on her wheelchair, and the resident responds with puzzled silence.

If you're predicting the surveyor is already thinking about handing out an F221 tag, you're right on the money.

When the surveyor in this real-life scenario could not get the resident to free herself, he concluded the facility had restrained the resident without following the required procedure outlined by the State Operations Manual.

The 'Rest of the Story'

The situation involving the resident who appeared restrained in her wheelchair occurred in a nursing home where physicians wrote orders for residents to use the self-release belts on their chairs as a "reminder" and not a restraint, according to a recent issue of the Delmarva Foundation for Medical Care's Nursing Home Quarterly. The physician order also stated that the residents were able to release the belts on their own. The nursing home staff had, in fact, confirmed on several occasions that the residents in question could release their belts when asked to do so.

But on survey day, the resident sat silently and immobile when the state inspector asked her repeatedly: "Can you release your belt?"

Asking for permission to intervene, the resident's caregiver used the words the resident was familiar with to ask her to remove the belt, which was a simple directive: "Please take off your belt, Mrs. Smith," explains Jacqueline Bell -Hairston, with Delmarva, which is the QIO for Maryland. Within seconds, the resident removed the belt and stood up on her own.

Lesson learned: Physician orders should be written in such a way that surveyors or anyone reading them would understand the order, says Bell-Hairston. "If the physician had written the order to say that Mrs. Smith needs to be told "take off your belt" in order to assess her ability to remove it on her own, the facility could have potentially avoided the problem with the surveyor," Bell-Hairston told Eli in an interview.

Facilities should also care plan that type of individualized information so any caregiver can assess the resident's ability to remove a self-restraint, which could change if the resident's cognitive or functional status declines.

To review the steps a facility must go through to use a restraint to treat a resident's documented medical symptom, see Appendix PP of the SOM at www.cms.hhs.gov/manuals/107_som/som107ap_pp_guidelines_ltcf.pdf (pp. 54-59).