MDS Alert

What’s really counted in your quality ratings regarding restraints.

If you use physical restraints at any time in your facility, will this tank your quality rankings? Not necessarily, but you need to know what exact methodology that the Centers for Medicare & Medicaid Services (CMS) uses to calculate your physical restraint quality measure (QM)

The physical restraint QM includes “any admission, annual, quarterly, significant change, significant correction, scheduled Prospective Payment System (PPS) or discharge MDS 3.0 assessment during the selected calendar quarter,” states QSource (www.qsource.org), part of the CMS Quality Improvement Organizations.

Considered a “long-stay” measure, the physical restraint QM’s numerator and denominator include residents whose “cumulative days in facility” is greater than 100.

“The numerator indicates the number of residents who triggered the QM, or the residents who ‘have’ the measured condition,” QSource explains. For the numerator, the resident would be counted if any of the following items are coded on the MDS as “2” (used daily):

• P0100B (trunk restraint used in bed) or P0100E (used in chair or out of bed)
• P0100C (limb restraint used in bed) or P0100F (used in chair or out of bed)
• P0100G (chair prevents rising used in chair or out of bed)

The denominator would include “the number of residents in the facility who could potentially have the measured condition, which includes all residents with a target assessment,” QSource explains.